Every finding on record at Riverside Health Services

Based on interview, record review, and facility policy review, the facility failed to revise the care plan for 1 (Resident #16) of 16 sampled residents. Specifically, Resident #16 requested to have a daily shower in June 2026, and the facility failed to revise and update the care plan with interventions related to the resident's choice for daily showers.Findings included: A facility policy titled, Resident Showers, implemented 09/01/2025 indicated, It is the practice of this facility to assist residents with bathing to maintain proper, circulation and help prevent skin issues as per current standards of practice. 1. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. An admission Record revealed the facility admitted Resident #16 on 05/06/2025. According to the admission Record, the resident had a medical history that included diagnoses of other cerebral infarction (stroke) and hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction affecting the left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2026, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS indicated that the resident required substantial to maximal assistance with showering and bathing of self. The quarterly MDS also revealed Resident #16 required substantial to maximal assistance with tub and shower transfers. Resident #16's Care Plan Report, revealed a focus area dated 08/26/2025, that indicated the resident's personal choices would be honored. Interventions directed staff to allow the resident to choose between a shower and a bath (initiated 08/26/2025). Resident #16's Progress Notes dated 06/18/2026 at 12:19 PM, indicated that a care plan meeting was held with the resident and the interdisciplinary team (IDT) members. The note further indicated that Resident #16 was concerned about not getting showers as requested. An undated facility document titled, Night Shift Showers, indicated that [Resident #16] gets a shower every night at 7:15 PM. Resident #16's Task List Report [a resident care guide for certified nurse assistants [CNAs]) dated 08/14/2026 revealed a task for showers/bathing every Tuesday, Thursday, and Saturday was initiated on 08/04/2025 and there had been no revisions to the Task List Report for daily showers. Resident #16's, Documentation Survey Report (a CNA task sheet) for June, July, and August 2026, revealed staff documented that the resident received shower supervision three times a week, Tuesdays, Thursdays, and Saturdays instead of a daily shower as indicated on the Night Shift Showers facility document. During an interview on 08/13/2026 at 2:29 PM, Resident #16 stated that they were supposed to get a shower every night at 7:15 PM but was only assisted with a shower every other night. During an interview on 08/14/2026 at 8:18 PM, CNA #5 stated the shower schedule was on a paper that was located at the nurses' station and on the inside of the linen cart. Per CNA #5, Resident #16 was supposed to receive showers daily at 7:15 PM. The CNA stated that for a majority of the time, the resident received a shower and did not refuse showers but would sometimes go to bed early and not take a shower. During an interview on 08/14/2026 at 8:48 PM, CNA #7 stated Resident #16 received showers every other night but could get a shower every night if the resident asked. The CNA stated she did not know the resident was supposed to be given a shower every night. During an interview on 08/15/2026 at 12:13 PM, the DON stated that daily showers for Resident #16 were supposed to begin June 2026. The DON stated that Resident #16's care plan and CNA tasks were not updated to reflect the change, and she did not know why. The DON stated that even though the resident's care plan was not updated, daily showers were written on the shower schedule, and her expectation was for the staff to follow the shower schedule and provide the resident with a shower daily. During an interview on 08/15/2026 at 2:43 PM, the Administrator stated Resident #16 started wanting daily showers around the first of June 2026 because it had started to get hot and the resident went outside a lot. The Administrator stated it was very important to review the task sheet and give the care the residents were supposed to receive on an individual basis. The Administrator stated that if the staff had questions about care, they were expected to go to the nurse. The Administrator also stated that she expected the staff to ask for help when needed.

Based on facility policy review, record review, and interview, the facility failed to implement their policy related to discussing advance directives at the time of admission to ensure residents had the right to formulate an advance directive, which affected 1 (Resident #3) of 2 residents reviewed for advance directives.Findings included: A facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated 03/26/2026, indicated, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives. The policy revealed, 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. An admission Record revealed the facility admitted Resident #3 on 06/11/2026. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure, tracheostomy status, and dependence on ventilator. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. A review of Resident #3's electronic health record (EHR) on 08/10/2026 at 3:42 PM revealed no evidence of advance directives or that advance directives had been discussed with the resident at the time of admission. During an interview on 08/12/2026 at 10:20 AM, the Business Office Manager (BOM) stated that she was unable to locate Resident #3's admission packet. The BOM confirmed that the resident had been a resident in the facility for two months. The BOM stated that the Social Services Director (SSD) was responsible for the admission packet; however, she was in the hospital, and staff were unable to locate the packet. During an interview on 08/14/2026 at 10:40 AM, Resident #3 stated they did not recall completing an admission packet, and advance directives were just discussed with them on 08/12/2026. During an interview on 08/15/2026 at 12:28 PM, the Director of Nursing (DON) stated that the SSD was responsible for completing the admission packets. The DON stated the admission packet should be completed the day the resident was admitted unless it was at night, then it would be completed the following day. The DON stated the facility had to have the paperwork in place, so she expected the advance directives to be discussed and documented upon admission. During an interview on 08/15/2026 at 1:32 PM, the Administrator stated she expected advance directives to be discussed upon admission, and if there were situations where that information could not be obtained on admission, then she expected it to be documented. The Administrator stated Resident #3 was cognitively intact, and it should not have been two months before the advance directives were discussed.

Based on interview and facility record and policy review, the facility failed to ensure a Registered Nurse (RN) was available to provide nursing services for at least 8 consecutive hours per day, 7 days per week, for 5 of 62 days during the months of January 2026 and March 2026Findings included: A facility policy titled Nursing Services-Registered Nurse (RN), implemented 09/01/2025, revealed, 1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week. (The requirement for 8 consecutive hours of RN services can be met by any RN or multiples of RNs. The hours worked by the DON [Director of Nursing] would be considered applicable towards the requirement.) The facility's staffing schedule and Staffing Assignments documents for the timeframe from 01/01/2026 through 03/31/2026 revealed that an RN was not available in the facility for the required 8 consecutive hours on 01/02/2026, 01/26/2026, 03/21/2026, 03/28/2026, and 03/29/2026. During an interview on 08/15/2026 at 10:29 AM, the DON reviewed the staffing documents and confirmed there was no RN coverage for the dates of 01/02/2026, 01/26/2026, 03/21/2026, 03/28/2026, and 03/29/2026. The DON stated she was responsible for the nursing schedule and stated there were only two RNs employed by the facility, one of which included the DON. The DON stated that she was present in the facility Monday through Friday and covered the weekend when the other RN was not working. During the interview, the DON stated that she tried to make sure every day was covered and was always available by phone. During an interview on 08/15/2026 at 2:43 PM, the Administrator stated that her expectation was for an RN to be in the building for a minimum of eight consecutive hours a day.

Based on interview, record review, and facility policy review, the facility failed to ensure a comprehensive person-centered care plan was developed to address high risk medications for 1 (Resident #42) of 15 resident care plans reviewed.Findings included: An undated facility policy titled, Comprehensive Care Plans, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. An admission Record revealed the facility admitted Resident #42 on 06/12/2026. According to the admission Record, the resident had a medical history that included cerebral infarction (stroke), embolism and thrombosis (blood clots) of unspecified artery, and type two diabetes mellitus. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/2026, revealed Resident #42 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS revealed the resident received insulin injections (hypoglycemic medication that lowers blood sugar levels) on seven days and received anticoagulant medication (medication that prevents blood clots from getting bigger and new clots from forming, often called a blood thinner) during the seven-day assessment look-back period. Resident #42's Order Summary Report, with active orders as of 08/12/2026, included an order dated 06/12/2026 for apixaban (anticoagulant medication) 5 milligrams (mg) via percutaneous endoscopic gastrostomy tube (feeding tube) two times a day, and an order dated 06/12/2026 for insulin glargine (long-acting insulin medication) solution 100 units per milliliter (ml), with instructions to inject 30 units subcutaneously daily for type 2 diabetes mellitus. Resident #42's Care Plan Report with an admission date of 06/12/2026, revealed no documented evidence that the facility developed a care plan for insulin and anticoagulant medications. During an interview on 08/14/2026 at 4:20 PM, the MDS Coordinator stated she was responsible for developing care plans and stated that the Director of Nursing (DON) reviewed them. The MDS Coordinator stated she did not know whether insulin or anticoagulant medication usage should be added to care plans. During an interview on 08/15/2026 at 12:28 PM, the DON stated that she reviewed care plans quarterly. The DON stated her expectation was for insulin and anticoagulant medications to be added to the care plan for residents receiving those medications. During an interview on 08/15/2026 at 1:32 PM, the Administrator stated that she expected medications to be added to the care plan. The Administrator stated that anticoagulants and insulins should be on the care plan because they required monitoring.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (North Hall medication cart) of 2 medication carts was locked when it was not within the line of sight of facility staff.Findings included: A facility policy titled, Medication Storage, implemented 01/09/2026, indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., [id est- means for example] medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. During a concurrent observation and interview of the North Hall on 08/10/2026 at 8:34 AM, the North Hall medication cart located at the beginning of the hallway was observed unlocked. The medication cart was observed open without any staff in direct observation of the medication cart. Certified Medication Aid (CMA #1) was observed coming out of a room next to the medication cart. CMA #1 stated that the medication cart should have been locked when unattended and that she had forgotten to lock the medication cart. During a concurrent observation and interviews of the North Hall medication cart on 08/13/2026 at 4:18 PM, the medication cart was observed unlocked in the hallway between two resident rooms, closest to the physical therapy department. There were no staff within a direct line of sight near the medication cart. The top drawer of the medication cart was easily opened and contained a medicine cup labeled for Resident #16 that contained two green pills, one purple capsule, one tan pill, and one white pill. Licensed Practical Nurse (LPN) #2 walked down from the opposite end of the hallway at 4:19 PM on 08/13/2026 and stated that CMA #3 was assigned to the medication cart and the cart should be locked when unattended. The Assistant Director of Nursing (ADON) then walked up to the medication cart, followed by the Director of Nursing (DON), at 4:19 PM on 08/13/2026. The ADON stated that the mediation cart should be locked when unattended. The DON also stated that medication carts should be locked when unattended, and that medications should not be left in medicine cups inside a medication cart drawer. During an interview on 08/14/2026 at 7:35 AM, CMA #3 stated that she should not have left the medication cart unlocked. During a concurrent observation and follow-up interview on 08/14/2026 at 2:45 PM, CMA #3 stated that on the previous day, the (North Hall) medication cart outside a resident's room, was unlocked, and that she had entered a resident room and closed the door. The Maintenance Director used a measuring tape to measure the distance from the medication cart to the doorway where the CMA was located with the door shut and stated the distance between them was 80 inches. An admission Record revealed the facility admitted Resident #16 on 05/06/2025. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke), seizures, and chronic pain syndrome. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2026, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #16's Order Summary Report, with active orders as of 08/15/2026, included an order dated 08/05/2025 for gabapentin 800 milligrams (mg) one tablet orally three times a day related to pain, and levetiracetam 500 mg, give one tablet orally two times a day related to other seizures, an order dated 07/23/2026 for warfarin sodium 2 mg, give one tablet in the evening related to other cerebral infarction, combine two 2.5 mg tablets equal to 7 mg, and warfarin sodium 2.5 mg, give two tablets by mouth in the evening related to other cerebral infarction. Take two tablets and combine with 2 mg tablet to equal 7 mg. During an interview on 08/13/2026 at 4:25 PM, the Administrator stated that the medication carts should be locked when unattended and that medications should not be left in a medicine cup in the drawer.

Based on interview, record review, and facility policy review, the facility failed to revise the care plan for 1 (Resident #16) of 16 sampled residents. Specifically, Resident #16 requested to have a daily shower in June 2026, and the facility failed to revise and update the care plan with interventions related to the resident's choice for daily showers.Findings included: An undated facility policy titled, Comprehensive Care Plans, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The policy further indicated, 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. An admission Record revealed the facility admitted Resident #16 on 05/06/2025. According to the admission Record, the resident had a medical history that included diagnoses of other cerebral infarction (stroke) and hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction affecting the left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2026, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS indicated that the resident required substantial to maximal assistance with showering and bathing of self. The quarterly MDS also revealed Resident #16 required substantial to maximal assistance with tub and shower transfers. Resident #16's Progress Notes dated 06/18/2026 at 12:19 PM, indicated that a care plan meeting was held with the resident and the interdisciplinary team (IDT) members. The note further indicated that Resident # 16 was concerned about not getting showers as requested, Resident #16's Care Plan Report, revealed a focus area dated 08/26/2025, that indicated the resident's personal choices would be honored. Interventions directed staff to allow the resident to choose between a shower and a bath (initiated 08/26/2025). There was no documented evidence that the facility revised the resident's care plan following the 06/18/2026 care plan meeting to include the resident's choice for a daily shower. Resident #16's, Documentation Survey Report (a certified nurse assistant [CNA] task sheet) for June, July, and August 2026, revealed staff documented that the resident received shower supervision three times a week, Tuesdays, Thursdays, and Saturdays. During an interview on 08/14/2026 at 8:45 AM, the resident stated that they first requested to have daily showers in December 2025. The resident stated that the plan was for them to receive daily showers at 7:15 PM. During an interview on 08/15/2026 at 12:00 PM, the MDS Coordinator stated that she was responsible for completing and updating resident care plans. The MDS Coordinator stated that she was at the care plan meeting for Resident #16, but she did not update the care plan to address the resident's request for daily showers. The MDS Coordinator stated that she did not know why she did not update the care plan for Resident #16. During a concurrent interview and review of Resident #16's care plan on 08/14/2026 at 9:32 AM, the Director of Nursing (DON) reviewed the resident's care plan and stated that it was not updated to include Resident #16's receiving daily showers. The DON stated that Resident #16 was originally scheduled for showers on Tuesdays, Thursdays, and Saturdays; however, the resident was supposed to start getting daily showers beginning in June 2026. During a follow-up interview on 08/15/2026 at 12:13 PM, the DON stated that she did not know why Resident #16's care plan was not updated to reflect the change to daily showers. During an interview on 08/15/2026 at 2:43 PM, the Administrator stated that care planning should include the care and services the facility was providing for the specific resident and their ADL needs. The Administrator stated her expectation was that care plans be reviewed and updated after care plan meetings and as needed.

Based on interview and facility policy and document review, the facility failed to ensure nurse staffing postings were completed daily for 3 of 3 days reviewed for nurse staff postings. This deficient practice had the potential to affect all 44 residents in the facility. A facility policy titled, Nurse Staffing Posting Information, dated 09/01/2025, revealed, It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. A facility document titled, Staffing Assignments, dated 08/04/2026, revealed no certified nurse assistants (CNA) information listed for the 7:00 AM through 7:00 PM shift and no listed census information. A facility document titled, Staffing Assignments, dated 08/07/2026, revealed no nursing staff information listed for the 7:00 AM through 7:00 PM shift and no listed census information. During an interview on 08/15/2026 at 10:29 AM, the Director of Nursing (DON) stated that the Restorative Aide (RA) completed the Staffing Assignments forms. The DON stated that every once in a while, the DON reviewed the staffing book, but there was no consistent review, and she did not review the hours for accuracy. During an interview on 08/15/2026 at 11:36 AM, the RA stated that she filled in the Staffing Assignments forms, and she did not know who completed the form when she was not at the facility. During an interview on 08/15/2026 at 2:33 PM, the DON reviewed the Staffing Assignments form, dated 08/04/2026, and stated the CNAs were not listed, the census was missing, and the hours were not accurate. The DON reviewed the Staffing Assignments form, dated 08/07/2026 and stated it was missing the entire day shift staff, the census, and the staffing hours. The DON stated the form was supposed to be completed in its entirety. During an interview on 08/15/2026 at 2:43 PM, the Administrator stated that the staff were required to be listed on the Staffing Assignments form, and the staffing hours were required on the back of the form. The Administrator reviewed the Staffing Assignments form, dated 08/15/2026, and identified the form was missing hours and the census. The Administrator stated the forms should be completed in their entirety.

Based on facility policy review, record review, and interview, the facility failed to ensure the state Ombudsman was notified of transfers and discharges, which affected 2 (Resident #6 and Resident #43) of 2 residents reviewed for hospitalizations and 1 (Resident #41) of 2 residents reviewed for change of condition.Findings included: A facility policy titled, Transfer and Discharge (including AMA [against medical advice]), dated 03/27/2026, indicated, It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. The policy revealed, 10. Emergency Transfers to Acute Care, which included h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. 1. An admission Record indicated the facility admitted Resident #6 on 10/19/2023. According to the admission Record, the resident had a medical history that included a diagnosis of cerebrovascular disease. Resident #6's Progress Notes included a note, dated 05/22/2026 at 6:51 PM, that indicated Resident #6 was lethargic and was sent to the hospital at 5:17 PM via emergency medical services. During an interview on 08/10/2026 at 11:29 AM, Resident #6 stated they went to the hospital about one month prior to the survey. During a telephone interview on 08/13/2026 at 1:39 PM, the Ombudsman stated the facility had not notified her of any transfers or discharges in a long time. The Ombudsman stated she was not in the office to verify when the last notification was, but it had been a while. During an interview on 08/14/2026 at 8:45 AM, the Administrator was asked for May 2026 Ombudsman notifications for transfers and discharges, and the Administrator stated the facility staff did not realize, until they were asked the day prior, that they needed to be sending the Ombudsman notification of transfers and discharges. The Administrator stated that they would be implementing that notification at the time of the immediately. 2. An admission Record indicated that the facility admitted Resident #41 on 09/08/2023. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia, muscular dystrophy, profound intellectual disabilities, and dependence on respirator (ventilator) status. The admission Record indicated that the facility discharged the resident on 06/07/2026 to an acute care hospital. Resident #41's Progress Notes included a note, dated 06/07/2026, that indicated that the resident was transferred to an acute care hospital after having an emergency event. During an interview on 08/13/2026 at 1:16 PM, the Director of Nursing (DON) stated the facility did not have an Ombudsman notification for discharges for June or July 2026. The DON stated the facility staff did not know that it was required to notify the Ombudsman of discharges. During a telephone interview on 08/13/2026 at 1:39 PM, the Ombudsman stated the facility had not notified her of any transfers or discharges in a long time. The Ombudsman stated she was not in the office to verify when the last notification was, but it had been a while. 3. An admission Record indicated the facility admitted Resident #43 on 10/22/2025. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure and cerebral infarction (a type of stroke). The admission Record indicated the facility discharged the resident on 07/06/2026 after being transferred to an acute care hospital. Resident #43's Transfer/Discharge Report indicated that the facility discharged the resident to an acute care hospital on [DATE]. During an interview on 08/13/2026 at 1:16 PM, the Director of Nursing (DON) stated the facility did not have an Ombudsman notification for discharges for June or July 2026. The DON stated the facility staff did not know that it was required to notify the Ombudsman of discharges. During a telephone interview on 08/13/2026 at 1:39 PM, the Ombudsman stated the facility had not notified her of any transfers or discharges in a long time. The Ombudsman stated she was not in the office to verify when the last notification was, but it had been a while. During an interview on 08/15/2026 at 12:28 PM, the DON stated she expected notifications to be sent to the Ombudsman. During an interview on 08/15/2026 at 1:32 PM, the Administrator stated she expected the Ombudsman to be notified as required for transfers and discharges.

Based on record review and interview, the facility failed to report an allegation of abuse to the state agency for 1 (#1) of 3 sampled residents reviewed for abuse.The DON identified 38 residents resided in the facility.Findings:An undated Abuse, Neglect and Exploitation policy, read in part, The facility will have written procedures that include: 1. Reporting of alleged violations to the administrator, state agency, adult protective services and to all other required agencies.An admission assessment, dated 01/22/26, showed Res #1 had a Brief Interview for Mental Status (a test for cognition) score of 3, which indicated severely impaired cognition.A physician progress note, dated 04/29/26 at 7:57 a.m., read in part, Follow-up evaluation conducted today regarding prior concerns of potential inappropriate physical contact involving the patient and spouse. There have been allegations of possible sexual behavior; however, no such activity has been witnessed by staff.On 05/06/26 at 11:00 a.m., the DON stated on 04/28/26, the administrator was notified by a certified nurse aide of concerns related to potential sexual contact between Res #1 and their spouse. The DON stated they immediately started an investigation but did not report the concerns to the health department.On 05/06/26 at 4:15 p.m., the administrator stated that all abuse allegations must be reported to the health department within two hours. The administrator stated this incident was not reported to the health department because they did not think it was an allegation of abuse.

Based on record review and interview, the facility failed to update the facility assessment as the acuity level of resident care increased. The DON identified 36 residents resided in the facility. Findings: A facility assessment, dated 10/15/25, read in part, Nursing facilities will conduct, document, and review a facility-wide assessment, which includes both their resident population and the resources that facility needs to care for their residents (42CFR SS483.71). The assessment will be reviewed annually and updated as needed.The purpose of the assessment is to evaluate the resident population and determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Use this assessment to make decisions about your direct care staff needs (including those who provide services under contract and volunteers), as well as your ability to provide services to the residents in your facility, at least annually and as necessary, for the above requirement. Using evidence-based, data driven methods focus on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practical physical, mental, and psychosocial well-being.The Facility assessment should drive staffing decisions and other resources and may include the operating budget necessary to carry out facility functions.A facility assessment, dated 10/15/25, showed one registered nurse needed for one day time shift per week (including weekends). The facility assessment showed a total of 10 licensed practical nurses were projected to be needed to provide care in a 24-hour period. The facility assessment showed seven licensed practical nurses were needed for the day shift, five licensed practical nurses for the evening shift, and four licensed practical nurses for the night shift. On 04/29/26 at 3:50 p.m., the DON stated the projected ten licensed practical nurses was not correct. The DON stated the DON (RN), assistant director of nursing (RN), and the minimum data set coordinator (LPN) were available to assist with resident needs during business hours, five days a week. The DON stated they assigned two LPNs to work the floor from 7a to 7p, and another two LPNs assigned to work the floor from 7p to 7a. The DON counted the number of licensed staff members available and stated there were seven licensed staff members available. The DON stated the acuity level of the residents was higher now than in October 2025 when the facility assessment was completed and they needed more staff to work directly with the residents.

Based on observation, record review, and interview, the facility failed to perform pressure ulcer care in a manner to prevent infection for 1 (#3) of 5 sampled residents reviewed for pressure ulcer care. A weekly wound flow sheet, dated 04/15/26, showed 11 residents with pressure ulcers. Findings:On 04/29/26 at 2:10 p.m., LPN #1 donned gloves and gown and entered Resident #3's room to provide pressure ulcer care. LPN #1 was observed to push personal items to one side and place two plastic trash bags on Resident #3's overbed table, next to the resident's personal items. LPN #1 did not sanitize the resident's overbed table prior to placing their dressing change supplies, bags, and gloves on the overbed table. CNA #1 and LPN #1 stepped to each side of the bed and positioned Resident #3 onto their right side. LPN #1 used their gloved hand to wipe feces from the Resident #3's upper left leg and buttock. LPN #1 then stepped back, and CNA #2 stepped to the side of the bed and provided incontinent care. CNA #1 and CNA #2 provided incontinent care, removed the soiled cloth bed pad, and placed a clean cloth bed pad under the resident. CNA #1 did not change gloves after wiping feces from the resident and before placing the clean cloth bed pad under the resident. Resident #3 was rolled from their left side and to their right side on the clean bed pad. After CNA #1 and CNA #2 repositioned Resident #3 onto their right side for pressure ulcer care, feces was still observed on the legs and buttocks of Resident #3. Wearing the same gloves, they had used to wipe feces from Resident #3's leg, LPN #1 was observed to cluster Resident #3's personal items together on the overed table, hand the oral suction yankauer to the resident, and to turn the portable suction machine on to suction. LPN #1 was observed to check the dressing supplies and to soak gauze in a cup of clear sound cleanser solution. Wearing the same gloves they used for incontinent care, LPN #1 obtained wet gauze from the cup of with their gloved fingers and used the soaked gauze to clean the remaining feces from Resident #3's legs and buttocks. LPN #1 then removed the old dressing cover and packing from the wound. Some of the packing was observed to have fallen onto the cloth bed pad. CNA #1 was observed to release Resident #3 which allowed the resident to make contact with the cloth bed pad/pillow with their back and buttocks. The contact occurred after the wound had been cleansed and application of medication had been applied but before the absorbent dressing cover was applied. Wearing the same gloves they used for incontinent care, LPN #1 cleaned the pressure ulcer. LPN #1 was observed to stick three fingers of their gloved hand into a plastic cup filled with a white paste and use their gloved fingers to apply the paste to the wound bed. LPN #1 doffed gloves and tossed them into the plastic trash bag on the overbed table. LPN #1 did not sanitize their hands before donning another set of gloves they had stored on the overbed table. LPN #1 applied the calcium alginate to the wound with their gloved fingers and then pulled open each pocket for CNA #2 to find keys to the dressing cart to obtain the absorbent dressing. LPN #1 was then observed to cover the wound with an absorbent dressing and secure with tape. On 04/29/26 at 3:00 p.m., LPN #1 stated the nurses assigned to work the floor were responsible for performing wound dressing changes. LPN #1 stated they felt nervous during the dressing change and could not remember the steps they needed to perform. LPN #1 stated they potentially contaminated their gloves when they wiped feces from the resident's left leg and potentially contaminated the resident's ventilation circuit, yankauer, suction, personal items on the overbed table, and wound care supplies having touched them with the potentially soiled gloves. LPN #1 stated since the resident still had feces on them when they were turned and positioned on the new cloth bed pad, the new bed pad became dirty and soiled. LPN #1 stated they contaminated their gloves when they used wet gauze to wipe feces from the resident before initiating the dressing change. LPN #1 stated they should have changed their gloves and the bed pad. LPN #1 stated they contaminated the wound bed when they used their gloved fingers to apply the collagen which they soaked in saline to make the paste. LPN #1 stated they should have used a tongue blade or applicator to apply the paste to the wound bed. LPN #1 stated they did not recognize Resident #3 was rolling back onto the soiled cloth bed pad between each step of the dressing change. LPN #1 stated the open pressure ulcer touching the bed pad could have potentially contaminated the ulcer. On 04/29/26 at 3:50 p.m., the DON was informed of the wound care observation. The DON stated they needed to provide their staff with more training and skills checks. On 04/29/26 at 4:30 p.m., Nurse Practitioner #1 stated the company they worked for provided wound care management to the facility residents. Nurse Practitioner #1 stated they had concerns with the dressing change the surveyor described to them. Nurse Practitioner #1 confirmed the DON was aware of the observation and stated they had training material which would be available to the DON and facility.

Based on observation, record review, and interview, the facility failed to prevent the development/worsening of pressure ulcers for 1 (#1) of 3 sampled residents reviewed for pressure ulcers. The ADON identified eight residents who currently had pressure ulcers. Findings: On 03/10/26 at 11:55 a.m., the ADON was observed to provide wound care for Resident #1. The resident had a pressure ulcer to the coccyx area. Resident #1 was observed to be lying on an air mattress. An undated Wound Treatment Management policy, read in part, Wound treatment will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. The baseline care plan, dated 11/21/25, showed Resident #1 currently had skin integrity issues. The care plan showed the staff was to apply zinc cream to Resident #1's bottom twice a day for prevention of skin breakdown. A nursing progress note, dated 11/27/25, showed a weekly evaluation. The evaluation showed Resident #1's skin was warm and dry, skin color was normal, and skin turgor was normal. An admission assessment, dated 12/02/25, showed the resident was severely impaired for daily decision making. The assessment showed the resident had diagnoses which included respiratory failure, tracheostomy status, parkinsonism, gastrostomy status, coronary artery disease, and renal insufficiency. The assessment showed Resident #1 was dependent on rolling from left to right. The assessment showed Resident #1 was at risk for developing a pressure ulcer. The assessment showed Resident #1 did not currently have a pressure ulcer. A nurse progress note, dated 12/06/25, showed Resident #1 had a new pressure ulcer to the left gluteus. The note showed the pressure ulcer was in house acquired, a stage 2 pressure ulcer, and was staged by in house nursing. The progress note showed the pressure ulcer had exposed dermis and measured 3.15 cm X 0.94 cm X 0 cm. The note showed the family, physician, and wound nurse were notified. An unsigned physician order, dated 12/07/25, showed the staff was to apply Mesitran Soft Wound External Gel (a wound dressing) to the left inner buttock topically in the morning, clean with wound wash, and pat dry. Apply medi-honey (a wound medication) to left inner buttock wound, cover with a dressing daily, and change as needed or when soiled. A care plan, dated 12/09/25, showed Resident #1 had impaired skin integrity. Interventions were to use positional devices to keep boney prominences from direct contact with each other, place therapeutic air mattress on bed, and monitor skin integrity every shift for breakdown and notify the physician for treatment orders. On 12/09/25 the intervention was to continue every hour turning schedule. A nursing skin evaluation, dated 12/22/25 at 2:21 p.m., showed Resident #1 had a new skin issue to the left ankle. The skin evaluation showed the resident had an unstageable pressure ulcer to the left ankle that was acquired in house. A progress note, dated 12/22/25 at 10:23 p.m., showed Resident #1 was sent by the physician to the emergency room with a blood pressure of 106/59, heart rate 118, and a temperature of 100.0 F. The treatment administration record for 12/2025, showed Resident #1 received wound care as ordered. A wound care clinical schedule, dated 12/12/25, did not show Resident #1 was seen by the wound care company. A physician order, dated 12/15/25, showed the staff was to apply Mesitran Soft Wound External Gel (wound dressing) to the left inner buttock topically two times a day, clean with wound wash, and pat dry. The staff was to apply medi-honey (a wound medication) and calcium alginate (a wound medication) to Resident #1's left inner buttock wound twice a day, cover with a dressing, and change the dressing as needed or when soiled. A history and physical form, dated 12/19/25, showed an initial assessment was completed by the nurse practitioner for the wound care company for Resident #1's pressure ulcer on the buttock. The form showed Resident #1's wounds had been present for five days and was unable to determine if the pressure ulcer was getting better or worse. The assessment classified the pressure ulcer as unstageable. The form showed the pressure ulcer to the buttock measured 2.54 cm X 5.23 cm X 0.4 cm. A nursing skin evaluation, dated 12/22/25 at 2:21 p.m., showed Resident #1 had a new skin issue to the left ankle. The skin evaluation showed the resident had an unstageable pressure ulcer to the left ankle that was acquired in house. A progress note, dated 12/22/25 at 10:23 p.m., showed Resident #1 was sent by the physician to the emergency room with a blood pressure of 106/59, heart rate 118, and a temperature of 100.0 F. A physician order, dated 12/22/25, showed the resident was to be turned every hour from left to right only. A progress note, dated 12/22/25, showed Resident #1 was sent by the physician to the emergency room with a blood pressure of 106/59, heart rate 118, and a temperature of 100.0 F. A hospital after visit summary, dated 12/23/25 -12/30/25, showed Resident #1 was hospitalized for a sacral decubitus ulcer stage 4, severe sepsis, fever, sepsis, elevated white blood cell count, chronic respiratory failure, and aspiration pneumonia. The hospital visit summary showed Resident #1 was discharged with an open wound to the left ankle and with wound care orders. A nurse note, dated 12/30/25, showed the resident returned to the facility with an order for Metroailazole (an antibiotic medication) 500mg tablet enterally every eight hours for 10 days for a wound infection. The task tab in the electronic health record for 01/26 and 02/26, showed the Resident #1 was not repositioned every hour per the physician orders. A wound care company progress note, dated 02/12/26, showed Resident #1 had a stage 2 pressure ulcer to the left lateral ankle that was first noted on 01/29/26. The progress note showed the treatment was to cleanse the wound with cleaner, apply honey and silver alginate, and cover with a dressing every other day and as needed. On 03/10/26 at 3:19 p.m., CNA #2 stated to prevent pressure ulcers for Resident #1 they were to reposition the resident every hour. The CNA could not recall other interventions. The CNA stated the task tab in the electronic health record was were documentation for repositioning Resident #1 every hour was located. On 03/11/26 at 12:00 p.m., the physician #1 stated they did not treat pressure ulcer/wound for the residents. The physician stated the facility had a wound care company who managed the resident wounds. The physician stated they did not write wound care orders or assess wounds at the facility. The physician stated they did not write the order for wound care for Resident #1 on 12/07/25. The physician stated if there was an order for wound care they did not write it. The physician stated the wound care physician might have given the wound care order. On 03/11/26 at 4:17 p.m., the nurse practitioner #1 for the wound care company stated they treated resident wounds in the facility once a week. The nurse practitioner stated they assessed and treated Resident #1's pressure ucler on 12/19/25. The nurse practitioner did not recall prior notification regarding pressure ulcers for Resident #1. On 03/12/26 at 8:48 a.m., the DON stated the wound care company was notified of residents who needed wound care by a list provided when the wound care company entered the facility weekly. The DON stated the list was usually completed by the administrator, ADON, or themself. The DON stated anyone could add a resident name to the list if a resident needed wound care. On 03/12/26 at 9:30 a.m., the DON reviewed the documentation regarding Resident #1 being turned and repositioned every hour. The DON stated per documentation the resident was not turned and repositioned every hour. On 03/12/26 at 12:00 p.m., the DON stated the wound care company was in the facility on 12/05/25, 12/12/25, and 12/19/25 for wound care. The DON stated Resident #1's pressure ulcer was identified on 12/06/26. The DON stated they did not know why the wound care company did not treat Resident #1's pressure ulcer when in the facility on 12/12/25. The DON stated Resident #1's pressure ulcer was treated on 12/19/25 by the wound care company.

Based on observation, record review, and interview, the facility failed to immediately notify the physician of a pressure ulcer for 1 (#1) of 3 sampled residents reviewed for a physician notification of a resident change in condition. The administrator identified 48 residents resided in the facility. Findings: On 03/10/26 at 11:55 a.m., the ADON was observed to provide wound care for Resident #1. The resident had a pressure ulcer to the coccyx area. Resident #1 was observed to be lying on an air mattress. An undated Notification of Changes policy, read in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.Circumstances requiring notification include: .Circumstances that require a need to alter treatment. A progress note, dated 11/27/25, showed a weekly nursing evaluation. The evaluation showed Resident #1's skin was warm and dry, skin color was normal, and skin turgor was normal. An admission assessment, dated 12/02/25, showed the resident was severely impaired for daily decision making. The assessment showed the resident had diagnoses which included respiratory failure, tracheostomy status, parkinsonism, gastrostomy status, coronary artery disease, and renal insufficiency. The assessment showed Resident #1 was dependent for rolling from left to right. The assessment showed Resident #1 was at risk for developing a pressure ulcer. The assessment showed Resident #1 did not currently have a pressure ulcer. A nurse progress note, dated 12/06/25, showed Resident #1 had a new pressure ulcer to the left gluteus. The note showed the pressure ulcer was in house acquired, a stage 2 pressure ulcer, and was staged by in house nursing. The progress note showed the pressure ulcer had exposed dermis and measured 3.15 cm X 0.94 cm X 0 cm. The note showed the family, physician, and wound nurse were notified. An unsigned physician order, dated 12/07/25, showed the staff was to apply Mesitran Soft Wound External Gel (a wound dressing) to the left inner buttock topically in the morning, clean with wound wash, and pat dry. Apply medi-honey (a wound medication) to left inner buttock wound, cover with a dressing daily, and change as needed or when soiled. The treatment administration record for December 2025, showed Resident #1 received wound care as ordered. A wound care clinical schedule provided by the DON, dated 12/12/25, did not show Resident #1 was to be seen by the wound care company. The DON stated they did not usually keep the lists provided to the wound care company. The DON stated they did not know why Resident #1 was not listed to be seen by the wound care company. A history and physical form, dated 12/19/25, showed an initial assessment was completed by the nurse practitioner for the wound care company for Resident #1's pressure ulcer on the buttock. The form showed Resident #1's wounds had been present for five days and was unable to determine if the pressure ulcer was getting better or worse. The assessment classified the pressure ulcer as unstageable. The form showed the pressure ulcer to the buttock measured 2.54 cm X 5.23 cm X 0.4 cm. A nursing skin evaluation, dated 12/22/25 at 2:21 p.m., showed Resident #1 had a new skin issue to the left ankle. The skin evaluation showed the resident had an unstageable pressure ulcer to the left ankle that was acquired in house. A progress note, dated 12/22/25 at 10:23 p.m., showed Resident #1 was sent by the physician to the emergency room with a blood pressure of 106/59, heart rate 118, and a temperature of 100.0 F. A hospital after visit summary, dated 12/23/25 -12/30/25, showed Resident #1 was hospitalized for a sacral decubitus ulcer stage 4, severe sepsis, fever, elevated white blood cell count, chronic respiratory failure, and aspiration pneumonia. A wound care company progress note, dated 02/12/26, showed Resident #1 had a stage 2 pressure ulcer to the left lateral ankle that was first noted on 01/29/26. On 03/11/26 at 12:00 p.m., the physician #1 stated they did not treat pressure ulcer/wound for the residents. The physician stated the facility had a wound care company who managed the resident wounds. The physician stated they did not write wound care orders or assess wounds at the facility. The physician stated they did not write the order for wound care for Resident #1 on 12/07/25. The physician stated if there was an order for wound care they did not write it. The physician stated the wound care physician might have given the wound care order. On 03/11/26 at 3:00 p.m., the ADON stated the wound care order for Resident #1 obtained on 12/07/25 was not signed by the physician. The ADON stated they did not recall who gave the order or how the order was received. On 03/11/26 at 4:17 p.m., the nurse practitioner #1 for the wound care company stated they treated resident wounds in the facility once a week. The nurse practitioner stated they assessed and treated Resident #1's pressure ulcer to the buttock on 12/19/25. The nurse practitioner did not recall prior notification regarding a pressure ulcer for Resident #1 prior to 12/19/25. On 03/12/26 at 8:48 a.m., the DON stated the wound care company was notified of residents who needed wound care by a list provided when the wound care company entered the facility weekly. The DON stated the list was usually completed by the administrator, ADON, or themself. The DON stated anyone could add a resident name to the list if a resident needed wound care. On 03/12/26 at 3:15 p.m., the ADON stated they did not notify the physician of Resident #1's wound. The ADON stated they were familiar with treatment the wound company used and thought they wound sign the order. The ADON stated writing orders was out of their scope of practice.

Based on record review and interview, the facility failed to ensure CMAs had the proper certifications to pass medications for 3 (#1, 2, and #3) of 8 sampled CMAs reviewed for certifications to pass meds via a gastrostomy tube.The DON identified 24 residents received medications through their peg tubes. An undated Medication Administration policy, read in part, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.1.On [DATE], upon reviewing CMA #1's certifications, CMA #1's advanced gastrostomy certification showed to have expired on [DATE].Resident #1's 10/2025 MAR showed CMA #1 had administered medications to Resident #1 on [DATE] through their peg tube (feeding tube into the stomach).2.On [DATE], upon reviewing CMA #2's certification, CMAs #2s advanced gastrostomy certification had expired on [DATE].Resident #1's 10/2025 MAR showed CMA #2 had administered medications to Resident #1 on [DATE], [DATE], and [DATE] through their peg tube.Resident #1's 11/2025 MAR showed CMA #2 had administered medications to Resident #1 on [DATE], and [DATE] through their peg tube.On [DATE] at 2:48 p.m., CMA #2 stated they were allowed to pass medications through a peg tube and do the feedings.3.On [DATE], upon reviewing CMA #3's certification, CMA #3's advanced gastrostomy certification had on [DATE].Resident #1's 10/2025 MAR showed CMA #3 had administered medications to Resident #1 on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] through their peg tube.Resident #1's 11/2025 MAR showed CMA #3 had administered medications to Resident #1 on [DATE], [DATE], [DATE], [DATE], and [DATE] through their peg tube.Resident #1's 12/2025 MAR showed CMA #3 had administered medications to Resident #1 on [DATE], [DATE], [DATE], [DATE], and [DATE] through their peg tube.On [DATE] at 10:51 a.m., the DON stated one of the nurses brought it to their attention a peg tube medication had already been administered, and CMA #1 was the only CMA not certified to work the medication carts. The DON stated they began an investigation and CMA #1 just never returned after being suspended.On [DATE] at 9:30 a.m., the DON stated the other two CMAs did have their certifications, but they were just not in the nurse aide registry. The DON stated they would get the proof from the school that tested them and provide that information.On [DATE], the facility did not provide documentation to show CMA #2 and CMA #3 had a certification to administer medications through a gastrostomy tube.

Based on observation, record review, and interview, the facility failed to update behavior care plans for 3 (#1, 2, and #4) of 3 sampled residents whose care plans were reviewed for their interventions in the management of routinely displayed inappropriate behavior. The DON identified three residents routinely displayed inappropriate behavior. Findings: 1. On 07/27/25 at 3:15 p.m., Resident #1 was observed entering the dining room. Resident #2 was observed sitting at a table in the corner of the dining room, with windows located on both walls of the corner. Resident #1 stopped and stared in the direction of Resident #2 for several minutes while mumbling unintelligible words under their breath. When Resident #1 was asked what they were saying, the resident only smiled and shook their head no. Several seconds later, Resident #2 smiled and pointed out the window as an ambulance arrived with their emergency lights on. A nurse's progress note, dated 02/09/25, showed Resident #1 yelled at other residents, attempted to grab other residents, punched another resident, blocked doorways/staff access to other residents, entered other resident rooms and refused to leave, and maneuvered up and down the hallway and screamed and yelled at other residents. The progress notes showed Resident #1 could not be redirected. Resident #1 was sent to the hospital, received haloperidol (an antipsychotic with a sedative effect) and returned to the facility with a diagnosis of agitation. An incident report, dated 02/09/25, showed Resident #2 reported to staff that Resident #1 struck them in the chest. The report showed Resident #2 struck Resident #1 across the face in retaliation.A nurse's progress note, dated 02/11/25, read in part, Conferenced with [resident's physician name withheld] in regards to recent aggressive/combative behaviors. A care plan, dated 02/11/25, showed Resident #1 was at risk for behaviors, including verbal outbursts. The care plan showed the goal was to be free from negative behaviors over the next 90 days. The care plan interventions included staff interacting with Resident #1 in a calm manner, medication administered per orders, behaviors to be monitored daily, behavior to be reported to the physician, and social services to visit the resident weekly. The care plan did not address what signs/symptoms may indicate potential escalation in negative behaviors, what negative behaviors the resident exhibited/staff were to monitor, what staff were to do when the resident exhibited negative behaviors, and/or how the staff were to protect Resident #1 and other facility residents when Resident #1 exhibited negative behaviors. A nurse's progress note, dated 03/10/25, showed Resident #1 grabbed the wheelchair of Resident #2. In response, Resident #2 grabbed the arm of Resident #1 which resulted in a 1cm x .01cm abrasion to the left forearm of Resident #1. The progress note showed the residents were separated and Resident #1 received treatment for their abrasion and education to ask for help with moving other residents' wheelchairs. An incident report, dated 03/10/25, showed Resident #1 exchanged words with Resident #2, then reached out and grabbed the wheelchair Resident #2 occupied. Resident #2 then grabbed Resident #1 around the arm and when Resident #1 pulled their arm away, they received a small abrasion to their lower left arm. A quarterly assessment, dated 06/09/25, showed Resident #1's speech was usually understood, the resident usually understood others, was severely impaired in cognition with a BIMS score of 0, and exhibited no behaviors. The assessment showed the resident had profound intellectual disabilities, psychotic disorder, depression, and anxiety. A nurse's progress note, dated 06/15/25, showed Resident #1 had increased agitation during the shift, yelled at other residents, accused others of calling the police and/or trying to hit Resident #1, and attempted to enter other resident rooms without their permission. The note showed redirection was used without success. A physician's progress note, dated 06/18/25, read in part, This is a [resident's age omitted] year-old .with behavioral disorder. [They've] been more aggressive and attempting to hit other residents within the facility. [They] will not talk .Impression: Behavioral disorder .Plan: it was discussed with [them] about [their] behaviors. The note showed the resident shook their head in understanding of the discussion. Staff were to continue to monitor and report behaviors. The progress note did not address interventions for the behaviors. A nurse's note, dated 06/22/25, showed Resident #1 woke in an agitated state and attempted to physically attack other residents assembled in the dining room for breakfast. The note read the staff's attempt to redirect was unsuccessful. A nurse's progress note, dated 07/20/25, showed Resident #1 had multiple verbal behavioral outburst toward other residents and staff members. The note showed staff utilized redirection, snacks, diversional activities, one on one time with staff, and family intervention were unsuccessful. On 07/21/25 at 3:25 p.m., Resident #5 stated Resident #1 would be great one day and another day be very adversarial. The resident stated when Resident #1 was adversarial toward them, they did the same back to Resident #1. Resident #5 stated at times, the staff would intervene, but it was not consistent. On 07/21/25 at 3:50 p.m., Resident #2 stated Resident #1 was always staring at them and mumbling negative comments about Resident #2 under their breath. Resident #2 stated Resident #1 followed them around throughout the facility, interrupted Resident 2, and told Resident #2 to shut up. Resident #2 stated they had saw Resident #1 try to hit other residents. Resident #2 stated they were tired of Resident #1 constantly pestering them and felt it was their right to live in the facility without someone causing them constant grief. On 07/21/25 at 4:00 p.m., CNA #4 stated Resident #1 and Resident #2 would routinely antagonize one another. CNA #4 stated they felt Resident #1 initiated the altercations more than Resident #2. CNA #4 stated they felt Resident #1 started the altercations 80 percent of the time, while Resident #2 initiated the altercations the other 20% of the time. CNA #4 stated other than to try and redirect the residents, they had no idea what to do and would probably go to their nurse for guidance. On 07/27/25 at 3:40 p.m., the administrator stated Resident #1 liked ambulances. The administrator stated Resident #1 had the mentality of a small child. The administrator stated Resident #1 would tell on you if you made them mad. The administrator stated Resident #1 did not like to answer questions. The administrator stated it was common for staff to shake their head when Resident #1 exhibited humorous behavior. On 07/27/25 at 5:20 p.m., CMA #1 stated there were primarily three residents that exhibited negative behaviors. CMA #1 stated some days Resident #1 would be fine and other days they would argue with Resident #2 over anything that came to mind, like the placement of their chair in the dining room. On 07/31/25 at 11:50 a.m., CNA #1 stated Resident #1 exhibited behaviors toward other residents and staff. CNA #1 stated Resident #1 would antagonize other residents and when the other resident responded back to Resident #1, Resident #1 would go and tell the nurse what the other resident stated and then return to agitate the other resident further. CNA #1 stated they would attempt to redirect the resident and ask Resident #1 to leave the situation/other resident alone and allow the staff to take care of the situation. CNA #1 stated if that did not work, they would go to the nurse. CNA #1 stated the facility did not in-service/train them on what to do if Resident #1 displayed negative behaviors. On 07/31/25 at 12:00 p.m., CNA #2 stated Resident #1 would not talk with them and was not sure what to do if Resident #1 displayed negative behaviors. CNA #2 stated the facility did not in-service/train them on what to do if Resident #1 displayed negative behaviors. On 07/31/25 at 12:10 p.m., CNA #3 stated Resident #1 could be understanding toward others and could be adversarial. CNA #3 stated Resident #1 might call someone stupid or something similar. CNA #3 stated if Resident #1 displayed negative behavior, they would give Resident #1 their space and return later. CNA #3 stated when the resident acted in a negative manner, it was usually due to a lack of good sleep. CNA #3 stated they saw Resident #1 purposely slam their wheelchair into another resident's wheelchair, but usually Resident #1 just used words when they displayed negative behaviors. CNA #3 stated the negative words were often directed toward Resident #2 and would escalate until Resident #2 yelled curse words back at Resident #1. CNA #3 stated Resident #1 would continue to yell negative statements such as you are stupid or shut up/don't talk back at Resident #2. CNA #3 stated Resident #1 would block Resident #2 from leaving a room or exiting the building. CNA #3 stated they could not reason with Resident #1 so they relied on Resident #2 to de-escalate the situation and would ask Resident #2 to go somewhere else to allow Resident #1 to calm down.On 07/31/25 at 12:28 p.m., LPN #1 stated Resident #1 had their own consistent routine and loved to watch emergency medical services and watch other residents in therapy. LPN #1 stated Resident #1 often thought other people were talking about Resident #1 and got agitated at the staff if they called their family after they refused care. LPN #1 stated Resident #1 felt the staff were telling on them. LPN #1 stated it was easier to reason with Resident #2 so Resident #2 was often asked to stay out of the way of Resident #1, but sometimes Resident #1 would block the exit and not let Resident #2 pass out of their way. LPN #1 stated when that happened, they would try to separate the two residents, reason with Resident #2, and try to redirect Resident #1 into an activity like watching other residents in therapy. LPN #1 stated most of the time that the interventions were effective, but when it was not effective, they contacted the family of Resident #1 or spoke with the DON/administrator. On 07/31/25 at 12:50 p.m., RN #1 stated Resident #1 was childlike in mentation and did not understand the insults and comments directed toward them, but did get upset with the encounter. RN #1 stated Resident #1 did not redirect well. RN #1 stated if Resident #1 saw Resident #2 engaged in a conversation with someone and Resident #2 used curse words or jokingly flipped the other person off, Resident #1 would take those comments, curse words, and gestures personally and get upset/agitated which in turn made Resident #2 upset. RN #1 stated they tried to keep the two residents separated, but Resident #2 had few activities of interest to do to keep occupied and Resident #1's behaviors directed toward them would quickly agitate Resident #2.On 07/31/25 at 1:10 p.m., the DON stated they expected their staff to redirect residents who displayed negative behaviors and if that did not work, ensure the resident was safe and ask to come back later to assist when the resident was more receptive to care. The DON stated that approach allowed the resident time to de-escalate. The DON stated sometimes the approach worked and sometimes it did not. The DON stated they encouraged care in pairs when staff provided care to a resident who displayed negative behaviors. The DON stated Resident #1 argued a lot with Resident #2. The DON stated if the staff intervened and redirected early in the argument, the two residents were easier to redirect. The DON stated often, all the staff had to do was separate the two residents with some distance and the two residents were alright. The DON reviewed the care plan for Resident #1 and stated the care plan did not address Resident #1's behaviors or what staff were to do when Resident #1 displayed negative behaviors. 2. On 07/27/25 at 3:15 p.m., Resident #2 was in the corner of the dining room, engaged with activities on an electronic tablet when Resident #2 was observed to enter the dining room, stop and stare in the direction of Resident #1, and mumble unintelligible words under their breath. An annual assessment, dated 12/21/24, showed Resident #2 was cognitively intact in daily decision making, and exhibited no mood or behavior issues. A nurse's progress note, dated 02/09/25, showed Resident #2 was in a physical altercation with Resident #1 and punched one another in the chest and shoulder. A care plan, updated 02/11/25, showed Resident #2 often spoke with staff in an inappropriate manner and set a goal for the resident to be free from negative behaviors over the next 90 days. The staff were to speak to the resident in a calm and professional manner, monitor the resident for behaviors daily, notify the physician of any behaviors, and social services were to visit the resident weekly. The care plan did not address physical altercations, what negative behaviors were to be monitored and where such behaviors were to be charted, what staff were to do when the resident exhibited negative behaviors, and/or how the staff were to protect Resident #2 and other facility residents when Resident #2 exhibited negative behaviors toward other residents. A nurse's progress note, dated 07/25/25, showed the resident was upset with staff and engaged each staff member individually to cuss at each of them separately. A quarterly assessment, dated 07/25/25, showed Resident #2 was cognitively intact in daily decision making, and exhibited no mood or behavior issues. A nurse's progress note, dated 07/29/25, showed the nurse spoke with the resident regarding their behavior toward another staff member. The nurse documented the resident called another staff member on their personal phone and talked to them in an inappropriate manner. On 07/31/25 at 12:00 p.m., CNA #2 stated Resident #2 would talk with the DON/administrator about their concerns. CNA #2 stated they were recently hired and had not received in-services on what to do if Resident #2 displayed inappropriate behaviors.On 07/31/25 at 12:10 p.m., CNA #3 stated Resident #2 would usually try to stay out of Resident #1's way. CNA #3 stated Resident #1 followed Resident #2 around the building or tried to block Resident #1 from leaving the dining room or going outside. CNA #3 stated Resident #2 had the larger vocabulary and would cuss at Resident #1. CNA #3 stated when the two were in an argument, they would try to talk with Resident #2 and get them to leave and give Resident #1 their space to calm down. CNA #3 stated that sometimes Resident #1 would not let Resident #2 leave a room or area and staff would help Resident #2 leave another way. On 07/31/25 at 12:28 p.m., LPN #1 stated Resident #2 and Resident #1 were friends and cycled through days when they would spend time together in common areas or out on the front porch and then there were other times when they antagonized one another. LPN #1 stated Resident #2 usually went out of their way to stay away from Resident #1, but sometimes Resident #1 would not get out of the way for Resident #2 to leave an area. LPN #1 stated the staff would try to separate the residents and assist Resident #2 out another facility door to give each resident time to calm down. LPN #1 stated it was easier to reason with Resident #2 and Resident #2 accepted redirection easier. LPN #1 stated when they could not redirect the resident, they would tell the DON/Admin. On 07/31/25 at 12:50 p.m., RN #1 stated if Resident #2 cussed or gave the finger to another resident in a jest, Resident #1 would take that personally and act out, even if the jest was not directed toward Resident #1. RN #1 stated this in turn upset Resident #2. RN #1 stated they tried to keep the two residents separated, but Resident #2 did not have much to do for activities and the facility was small which made separation harder to accomplish. On 07/31/25 at 1:10 p.m., the DON stated they expected their staff to redirect residents who displayed negative behaviors and if that did not work, ensure the resident was safe and ask to come back later to assist when the resident was more receptive to care. The DON stated that approach allowed the resident time to de-escalate. The DON stated sometimes the approach worked and sometimes it did not. The DON stated they encouraged care in pairs when staff provided care to a resident who displayed negative behaviors. The DON stated Resident #2 argued a lot with Resident #1. The DON stated if the staff intervened and redirected early in the argument, the two residents were easier to redirect. The DON stated often, all the staff had to do was separate the two residents with some distance and the two residents were alright. The DON reviewed the care plan for Resident #2 and stated the care plan did not address Resident #2's behaviors or what staff were to do when Resident #2 displayed negative behaviors. 3. On 07/21/25 at 2:30 p.m., Resident #4 was heard to repeatedly yell out for help, pause, yell another resident's name, and say that the other resident was homosexual. Resident #4 stopped yelling for brief moments and then resumed the same statements throughout the day. On 07/27/25 at 12:29 p.m., Resident #4 was heard to repeatedly yell out for help, pause, yell another resident's name, that the other resident was homosexual, and performed certain sexual acts. Resident #4 stopped yelling for brief moments and then resumed the same statements throughout the day.A comprehensive assessment, dated 10/26/24, showed Resident #4 was moderately impaired in daily decision making with a BIMS score of 11, denied any concerns with mood, and displayed no behaviors. The assessment showed the resident's diagnoses included quadriplegia, seizure disorder, anxiety, and depression. A nurse's progress note, dated 01/02/25, showed Resident #4 observed another resident pass by the door to their room, immediately threw their hamburger into the hallway, and stated they hated 'that [explicit language].A nurse's progress note, dated 01/10/25, showed Resident #4 threw their cup toward a staff member and into the hallway, continuously used profanity and inappropriate language toward staff, stated they hated the facility and the people within it. The note showed Resident #4 threatened to throw their urine filled urinal at staff and threatened to throw their self out of their bed.A nurse's progress note, dated 02/15/25, showed Resident #4 used inappropriate language, profanity, and propositioned staff. The note showed Resident #4 was instructed their behavior and language was not appropriate and Resident #4 stated they did not care. A care plan, dated 02/19/25, showed Resident #4 had inappropriate behaviors and the goal was for Resident #4 to understand the need to control their inappropriate behaviors. The interventions listed were to make clear what the limitations were, assess resident's understanding of the situation, nursing staff were to monitor and record inappropriate behavior as it occurred, monitor frequently when there was an increase in behavior, and social services were to visit weekly. The care plan did not address what inappropriate behaviors Resident #4 displayed, how the staff were to ensure Resident #4 had a clear understanding of the need to control inappropriate behaviors, what limitations the staff were to make clear to Resident #4, who was responsible to address Resident #4 on the limitations, and how they were to address the limitations with Resident #4, what inappropriate behaviors the staff were to monitor/monitor frequently for, where staff were to document the monitored behaviors, how the staff were to protect Resident #4 and other facility residents when Resident #4 exhibited inappropriate behaviors, and what were staff to do/how were staff to provide care when the resident exhibited inappropriate behaviors. A nurse's progress note, dated 02/21/25, showed Resident #4 shouted inappropriate language and profanity towards staff members. A nurse's progress note, dated 03/10/25, showed Resident #4 said sexually inappropriate statements. A nurse's progress note, dated 03/19/25, showed Resident #4 exhibited socially inappropriate behavior, threw their urine filled urinal several times, which resulted in urine on the floor and walls. The note showed Resident #4 frequently yelled for staff instead of using the call light. A nurse's progress note, dated 03/16/25, showed Resident #4 shouted profanity and inappropriate language towards their roommate and staff members throughout the night. A nurse's progress note, dated 05/12/25, showed Resident #4 spit at staff and slapped the staff's buttocks. A nurse's progress note, dated 05/23/25, showed Resident #4 talked inappropriately toward a staff member and forcefully grabbed a part of the staff member's anatomy. The note showed the staff asked Resident #4 to stop and Resident #4 became angry and continued to make inappropriate comments toward the staff member. The progress note showed Resident #4 threw their full urinal against the bathroom door, which caused urine to splatter on the door, walls, window, and floor. When the staff approached Resident #4, Resident #4 stated, I don't [explicit language] care.A nurse's progress note, dated 05/26/25, showed Resident #4 was rude and inappropriate with staff during activities of daily living, cussed at staff, and used offensive gestures toward staff.A nurse's progress note, dated 06/10/25, showed Resident #4 used inappropriate language toward staff. A nurse's progress note, dated 06/30/25, showed Resident #4 squeezed a staff member's behind and when the staff removed the resident's hand, Resident #4 shouted they hated everyone in the facility and if they could acquire a gun Resident #4 would shoot everyone in the facility. A nurse's progress note, dated 07/01/25, showed Resident #4 exhibited multiple negative or socially inappropriate behaviors during their shift. No interventions were documented.A nurse's progress note, dated 07/11/25, showed Resident #4 continued to use sexually inappropriate language and gestures toward staff and resident redirection was attempted without success. A nurse's progress note, dated 07/17/25, showed Resident #4 continued to use sexually inappropriate and vulgar language toward staff. A nurse's progress note, dated 07/20/25, showed Resident #4 stated sexually inappropriate comments toward staff and residents. The note showed staff attempted to redirect Resident #4 several times without success. A nurse's progress note, dated 07/23/25, showed Resident #4 continued sexually inappropriate behaviors toward staff. The note showed staff attempted redirection and diversional activities with Resident #4, but there was no change in their behavior. The note showed Resident #4 yelled toward staff and other residents when they were seated in the common room.A nurse's progress note, dated 07/27/25, showed Resident #4 continued to use inappropriate language. A nurse's progress note, dated 07/28/25, showed Resident #4 used foul language towards staff.A quarterly assessment, dated 07/28/25, showed Resident #4 was severely impaired in daily decision making with a BIMS score of 6, denied any concerns with mood, and displayed verbal behaviors toward others. The assessment showed Resident #4 had diagnoses which included stroke, anxiety, depression, and other sexual disorders. A nurse's progress note, dated 07/30/25, showed Resident #4 had multiple negative or socially inappropriate behaviors during their shift. On 07/27/25 at 11:50 a.m., CNA #4 stated Resident #4 had no verbal filter and directed their remarks primarily toward staff but did yell out obscenities toward another resident as well, calling the other resident homosexual and such. On 07/31/25 at 11:50 a.m., CNA #1 stated Resident #4 was very vocal with what they were thinking. CNA #1 stated the resident was often inappropriate and addressed CNA #1 as their eight-year-old baby (boy/girl) in a derogatory tone/manner. CNA #1 stated when staff used the manual crank on the transfer lift to lift and transfer Resident #4 to/from their chair, Resident #4 would say things like pump it baby, pump it! CNA #1 stated their experience had taught them not to acknowledge the comment or respond to the comment. CNA #1 stated Resident #4 inappropriately touched another CNA while they assisted the resident. CNA #1 stated they were not in-serviced or trained on what to do when Resident #4 exhibited negative behaviors. On 07/31/25 at 12:00 p.m., CNA #2 stated Resident #4 was a character and said sexual things toward the staff but the staff did not respond to the resident's comments. CNA #2 stated Resident #4 grabbed their side and said something they were sure was rude, but they were too shocked from Resident #4 touching them to hear what Resident #4 said. CNA #2 stated they asked Resident #4 not to grab them and Resident #4 removed their hand from the CNA's side. CNA #2 stated they were not in-serviced on what to do when Resident #4 displayed negative behaviors. On 07/31/25 at 12:10 p.m., CNA #3 stated Resident #4 was very vulgar. CNA #3 stated they tried to talk with Resident #4 and asked that they not say such comments. CNA #3 stated Resident #4 would throw their full urinal across the room so the staff would have to clean the room and Resident #4 could talk with the staff. CNA #3 stated Resident #4 often made fun of another resident, calling the other resident a faggot. CNA #3 stated the other resident just ignored Resident #4 and did not appear to be disturbed by the outbursts. CNA #3 stated when they asked Resident #4 why they yelled such things toward the other resident, Resident #4 stated they did not like the other resident. CNA #3 stated they were not in-serviced on what to do when Resident #4 displayed negative behaviors. On 07/31/25 at 12:28 p.m., LPN #1 stated Resident #4 did not talk nicely to the CNAs. LPN #1 stated they instructed the CNAs to report the resident's behavior to the administration. LPN #1 stated they instructed their CNAs to ask the resident not to talk that way toward the CNAs and offer to step away until Resident #4 was ready to receive assistance. LPN #1 stated they expected the CNAs to make sure Resident #4 was safe and then go tell administration about the resident's behavior. LPN #1 stated sometimes redirection worked for Resident #4 and sometimes it did not. LPN #1 stated they were not aware of a behavior care plan for Resident #4. On 07/31/25 at 12:50 p.m., RN #1 stated Resident #4 did not treat the RN as Resident #4 treated other staff and did not make sexual remarks toward the RN. RN #1 stated they did not give Resident #4's behaviors much attention and felt that the lack of attention helped to curb Resident #4's negative behaviors. RN #1 stated Resident #4 stopped their inappropriate behavior when RN #1 asked it of them. RN #1 stated the staff were to provide all resident care with another staff member present. RN #1 stated they felt having a witness in the room helped some but it did not change Resident #4's behaviors. On 07/31/25 at 1:10 p.m., the DON stated they expected their staff to redirect residents who displayed negative behaviors and if that did not work, ensure the resident was safe and ask to come back later to assist the resident when the resident was more receptive to care. The DON stated that approach allowed the resident time to de-escalate. The DON stated sometimes the approach worked and sometimes it did not. The DON stated they encouraged care in pairs when staff provided care to a resident who displayed negative behaviors. The DON reviewed the care plan for Resident #4 and stated the care plan did not address Resident #4's behaviors or what staff were to do when Resident #4 displayed negative behaviors.

On 03/03/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have a system in place to ensure dependent residents were repositioned every two hours to prevent new and worsening pressure ulcers. On 03/03/25 at 6:00 pm, the OSDH was notified and verified the existence of the IJ situation. On 03/03/25 at 6:15 p.m., the facility administrator and DON were notified of the IJ situation and provided a copy of the IJ template. On 03/05/25 at 10:06 a.m., an acceptable plan of removal was submitted to the OSDH. The plan of removal, read in part, 1. DON/Designee Completed 100% Care Plan Audit to ensure Interventions are in place to prevent further Skin Breakdown on 3/3/25 and 3/4/25. 2. DON/Designee In-serviced Licensed Nursing Staff on 3/3/25 regarding: Facility Policy on Turn Schedule. Repositioning Policy and Procedure. Shift Documentation of ADL Care including Turning and Repositioning. 3. DON/ADON Completed 100% Skin Sweep with No New Skin Issues Identified on 3/3/25. 4. RNC [regional nurse consultant] In-serviced Admin [administrator]/DON/ADON and Provided Education on Interventions to prevent Skin Breakdown on 3/3/25. All In-services to Licensed Nursing Staff were completed on 3/3/25 by 2000 [8:00 p.m.]. 1. DON/Designee In-serviced CNA/CMA Staff on 3/3/25 regarding: Facility Policy on Turn Schedule. Repositioning Policy and Procedure. Shift Documentation of ADL Care including Turning and Repositioning 2. Resident #2 wound was assessed on 3/4/25 upon return from Hospital and noted to have declined with 3 New Non-Facility Acquired Wounds. 3. DON/Designee Verified Physician and Family are Aware with Appropriate Treatments in Place. 4. Resident #2 will be followed weekly by [name withheld] Wound Specialists. 5. Documented Turn and Repositioning Schedule initiated 3/3/35 at 2000 [8:00 p.m.]. All In-services to CNA/CMA completed on 3/3/24 by 2000. On 03/05/25 at 5:22 p.m., the IJ was removed when all components of the plan of removal had been verified. The deficiency remained as an isolated level with potential for more than minimal harm. Based on observation, record review and interview, the facility failed to have a system in place to ensure dependent residents were repositioned every two hours to prevent new and worsening pressure ulcers for 1 (#2) of 3 sampled residents reviewed for pressure ulcers. The DON identified five residents in the facility with pressure ulcers. Findings: On 3/03/25 at 5:15 p.m., a tour of the facility was conducted with the DON. The repositioning schedule in the ADL book showed dependent residents were be positioned on their right side from 4:00 p.m. until 6:00 p.m. Zero out of 32 dependent residents were observed to be positioned on their right side. An undated facility policy titled Repositioning read in part, A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated .Residents who are in bed should be on at least every two hour ([every]2 hour) repositioning schedule. Resident #2 had diagnoses which included chronic respiratory failure. A skin assessment, dated 11/25/24, showed Resident #2 was at high risk for developing a pressure ulcer. A care plan, date initiated 11/25/24, showed Resident #2 was to be turned and repositioned every two hours. An admission minimum data set assessment, dated 12/02/24, showed Resident #2 was totally dependent on staff for repositioning and did not have any pressure ulcers upon admission. The assessment also showed Resident #2 was on a turning/repositioning program. A nurse note, dated 01/10/25 at 4:00 p.m., showed Resident #2 was found to have a fluid filled blister to the left buttock and an open area to the right buttock. The note also showed the physician was notified and wound care orders were received. A physician order, dated 01/10/25, showed Resident #2 was to receive daily wound care. The order showed the wound was to be cleaned with normal saline, patted dry, then Bactroban was to be applied, and the wound was to be covered with foam dressing. A physician order, dated 01/20/25, showed Resident #2 was to receive daily wound care. The order showed the wound was to be cleaned, patted dry, Hydrogel was to be applied, and the wound was to be covered with a padded dressing. A wound progress note, dated 01/27/25, showed Resident #2 had an unstageable pressure ulcer to the sacrum measuring 5.0 cm x 4.0 cm x 0.1 cm. The note also showed the wound had very little drainage and no odor. A wound progress note, dated 02/03/25, showed Resident #2 had an unstageable pressure ulcer to the sacrum measuring 7.0 cm x 5.0 cm x no depth documented. The note also showed the wound had very little drainage and no odor. A wound progress note, 02/10/25, showed Resident #2 had an unstageable pressure ulcer to the sacrum measuring 8.0 cm x 5.5 cm x no depth documented. The note also showed the wound had a moderate amount of drainage and a foul odor. A nurse note dated 02/10/25 at 4:07 p.m., showed Resident #2's wound was declining as evidenced by a foul odor, brown/yellow slough on the wound bed and moderate amounts of yellow/brown drainage. The note also showed the physician was notified and orders were received. A nurse note dated 02/17/25 at 11:00 a.m., showed Resident #2 was lethargic and would not arouse to a sternal rub, the note showed the physician was notified and the resident was being sent to the hospital. The note showed the wound to the sacrum now measured 6 cm x 8 cm x 1.5 cm with undermining from 6-12 o'clock. On 02/24/25 at 2:45 p.m., CNA #1 stated that dependent residents were turned every two hours and the ADL book at the nurse's desk told them what position the residents should be in at any given time. CNA #1 stated they did not document when residents were turned. On 02/24/25 at 2:47 p.m., CNA #2 stated the ADL book told them what position the residents needed to be in, but they did not document the residents had been repositioned. On 02/24/25 at 3:04 p.m., LPN #2 stated they made rounds to ensure residents were being turned. An After Visit Summary, dated 02/26/25, Showed Resident #1's primary hospital diagnosis was a pressure sore on the sacrum. The summary also showed additional diagnoses which included sepsis. A nurse note, dated 02/26/25 at 1:00 p.m., showed that Resident #2 had returned from the hospital with a diagnosis of pressure ulcer to the sacrum and VRE in the urine and wound. On 03/03/25 at 4:32 p.m., LPN #2 stated they did not have a list of residents that should be repositioned every two hours. On 03/03/25 at 4:33 p.m., CNA #8 stated the ADL book had a list of residents that required repositioning every two hours. CNA #8 reviewed the ADL book and stated that it did not contain a list of residents that required repositioning. CNA #8 then stated all dependent residents should be turned every two hours. CNA #8 stated they did not document when a resident was turned or if they refused to be turned. On 03/03/25 at 4:37 p.m., CNA #3 stated they did not have a list of who needed to be repositioned, and they did not document when a resident was turned or when a resident refused to be repositioned. On 03/03/25 at 4:45 p.m., the DON stated the CNAs documented in the ADL book when residents were repositioned. After reviewing the ADL book, the DON stated it was not being documented when residents were repositioned. They also stated that if a resident refused, the CNA should notify the charge nurse and document the resident refused. The DON stated the charge nurses and the DON should be monitoring to ensure the CNAs were repositioning residents as ordered and documenting when the residents were repositioned. On 03/03/25 at 5:20 p.m., the DON stated dependent residents should be on their right side until 6:00 p.m., but they were not. They also stated residents were not being repositioned appropriately.

Based on record review and interview, the facility failed to ensure complete and accurate documentation for 1 (#2) of 5 sampled residents reviewed for complete and accurate medical records. The DON reported the facility census was 39. Findings: A facility policy titled Charting and Documentation, revised 07/2017, read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Resident #2 was admitted on [DATE] and had diagnoses which included chronic respiratory failure. A review of Resident #2's medical records did not show any physician progress notes for Resident #2. On 03/03/25 at 1:17 p.m., physician #1 stated they had seen Resident #2 in person a couple of times since there was a wound noted on 01/10/25. They also stated they had documentation of these visits at the office. On 03/03/25 at 3:15 p.m., the DON stated physician #1 had seen Resident #2 in person on 01/15/25 and 02/12/25. They stated Resident #2's medical records did not contain documentation of these visits.

Based on record review and interview, the facility failed to provide RN coverage for eight consecutive hours seven days per week during 2 (October 2024 and January 2025) of 4 months reviewed for having RN coverage for eight consecutive hours seven days per week. The administrator identified 40 residents resided in the facility. Findings: The CASPER report for fisal year Quarter 4 2024 triggered for no RN coverage on four or more days within the quarter. A review of payroll documents for October 2024 and January 2025 showed there was no RN coverage on the following days since the last period covered on the CASPER report: October 5-6, 12-13, and 26-27 and January 5, 12, 19, and 26. On 02/05/25 at 4:44 p.m., the business office manager was asked if they had submitted all of the documents to verify RN coverage for October 2024 and January 2025. They stated that was all they could account for in their punch system. They stated the DON did not punch, but completed missed visit forms. They stated they gave all that they had. On 02/06/25 at 8:24 a.m., the DON acknowledged there was no RN coverage on the dates listed above.

Based on record review and interview, the facility failed to ensure a resident with a new diagnosis of a serious mental health condition had a PASARR updated for 1 (#7) of 1 sampled resident reviewed for PASARR level ll. The DON identified nine residents with serious mental health diagnoses. Findings: Resident #7 had diagnoses which included pseudobulbar affect and a mood affective disorder. A PASARR level l, dated 10/26/18, showed the resident did not have a diagnosis of serious mental illness or other psychotic disorder. The annual assessment, dated 11/09/24, showed the resident currently was not considered by the state PASARR level II process to have serious mental illness and/or intellectual disability or a related condition. On 02/04/25 at 2:57 p.m., the DON reviewed the resident's clinical record and stated the resident had a diagnosis of mood affective disorder and a psychotic disorder. The DON stated a PASARR level ll referral should have been made to the Level of Care Evaluation Unit.

Based on record review and interview, the facility failed to ensure resident assessments were submitted to CMS within 14 days of completion for 40 of 40 residents. The Resident Census and Conditions of Residents, dated 12/29/22, documented a census of 40 residents. Findings: The MDS Completion and Submission Timeframes policy, dated July 2017, read in parts, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .The assessment coordinator .is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines . The facility did not provide Final Validation Reports to show resident assessments were submitted to CMS. A review of resident assessments for 40 of 40 residents was conducted which showed no resident assessments had been submitted from 08/09/22 to 12/30/22 at 1:36 a.m. On 12/30/22 at 3:28 p.m., the Administrator reported no one had log in credentials to submit resident assessments to CMS.

On 03/22/17 at 5:45 p.m., the Oklahoma State Department of Health (OSDH) was notified an immediate jeopardy situation was determined to exist related to the facility's failure to ensure residents who were admitted with a pressure ulcer were identified as having a pressure ulcer and appropriate assessment and monitoring were provided to ensure pressure ulcers were able to heal and residents did not develop additional pressure ulcers. On 03/22/17 at 6:01 p.m., the administrator and DON were notified of an immediate jeopardy situation regarding resident #2 being re-admitted to the facility on [DATE] and not having pressure ulcers assessed and measured until 03/20/17 when the surveyor asked for the resident's wounds to be measured. The resident was found to have 10 wounds and the facility had no documented assessments or measurements. The administrator and DON were informed the IJ was related to the facility's failure to accurately and consistently assess and monitor pressure ulcers. The administrator and DON were asked to provide a plan of removal. On 03/22/17 at 8:22 p.m., the administrator provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: Riverside Health Services Arkoma Plan of removal Full skin assessments 3/22/17 residents with wounds. 3/22/17 immediate assessment, measurement, documentation of wounds. 3/22/17 Need for for wound treatment orders from PCP will be done immediately. Nursing staff will be educated by the DON or designee on 3/22/17 regarding the requirement to document the status of any wounds at time of admission and on a consistent established weekly recurrence schedule. DON/ADON will review and revise as needed the policy and procedure regarding wounds by 3/22/17 to include: Screening for pressure risk. Assessment of present wounds and all measurements documented. Physician notification Location of documentation will occur in skin check sheet area then wound pressure grafting area in software supported by narrative documentation from the nurse. All residents have the potential to be affected. Monitoring/tracking All records for residents with wounds will be reviewed each week by DON or designee. DON or designee will assist assigned staff nurse once weekly for wound assessments to help determine improvement /effectiveness of treatments and notify physician Ongoing for future QA review weekly by administration and medical director for 8 weeks an upon admission and readmission-ongoing. On 03/23/17 at 4:04 p.m., an addendum to plan of removal documented: All residents with wounds will be immediately re-assessed by the DON/Designee which will include wound staging. Wounds documented as unstageable will include reason they are unstageable. All other wounds will be documented descriptive findings. All wound assessments will be completed by 8:00 pm 3/23/17. On 03/27/17 at 10:40 a.m., facility nursing staff was interviewed regarding the facility's policy on skin and wound assessments and the consistent monitoring of the pressure ulcers. The nursing staff verbalized understanding. The administrator was informed the immediacy had been lifted effective 03/23/17 at 8:00 p.m. The administrator was informed the deficiency remained at a harm level at a pattern and the facility remained in substandard quality of care. Based on observation, interview, and record review, it was determined the facility failed to ensure residents admitted with pressure ulcers received the necessary treatment and services to ensure healing and prevention for the development of other pressure ulcers for three (#2, #5, and #6) of eight resident who were sampled for pressure ulcers. The facility failed to provide thorough assessments and consistent monitoring for residents with pressure ulcers. The facility identified six residents with pressure ulcers. Resident #2 being re-admitted to the facility on [DATE] and did not have pressure ulcers assessed and/or measured until 03/20/17 when the surveyor asked for the resident's wounds to be measured. The resident was found to have 10 wounds and the facility had no documented assessments or measurements. Findings: The facility policy on pressure ulcer prevention documented if a pressure ulcer was present, the licensed nurse was responsible to record the condition of the skin, including the stage, size, depth,color, and odor, as well as the treatment provided. The policy documented notification of the residents physician was required when a new pressure was identified as well as when treatments were not effective. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing note, dated 12/29/16, documented Late entry for 12/28/16. The nurse note documented the resident was admitted with the following [DIAGNOSES REDACTED]. The nurse note did not document the measurements of the decubitus. The nurse note documented the resident required total assistance with activities of daily living. The note documented the resident had a suprapubic catheter. The nurse note documented the resident communicated by sounding out words with his lips. A narrative note, dated 12/29/16, documented new treatment orders. The narrative note documented the resident was to have [MEDICATION NAME] and an ABD pad applied to the red areas on the neck fold under [MEDICAL CONDITION] x seven a days, then re-evaluate. The narrative note documented the resident had an open area on the sacrum measuring 6.4 centimeters (cm) x 6.6 cm x 2.2 cm with 4.2 cm tunneling. Then narrative note documented to apply [MEDICATION NAME] and a foam pad every day x seven days to the sacrum, then re-evaluate. A skin assessment sheet, dated 12/31/16, documented the resident had an abrasion to his left shoulder, redness around his neck fold below [MEDICAL CONDITION], and an open area to the sacrum measuring 6.4 cm x 6.6 cm 2.2 x cm with 4.2 cm tunneling. A skin check sheet, dated 01/05/17, documented the resident had a 2 cm x 2 cm abrasion to the back of his left shoulder. The skin check sheet documented the resident had an ulcer on his sacrum that measured 6.2 cm x 6.4 cm x 2 cm with 4 cm tunneling. The skin check sheet documented the treatment orders as Demagran ointment to the neck, [MEDICATION NAME] to the sacrum, and Xeroform to the left shoulder. An admission assessment, dated 01/09/17, documented the resident was rarely or never understood. The assessment documented the resident exhibited verbal behaviors towards others 4-6 days a week. The assessment documented the resident required total assistance with bed mobility, transfers, and activities of daily living. The assessment documented the resident had an ostomy and a catheter. The assessment documented the resident had a tube feeding. The assessment documented the resident was at risk of developing a pressure ulcer. The assessment documented no skin problems or pressure ulcers. The assessment documented the resident required oxygen therapy, suctioning, [MEDICAL CONDITION] care, and a ventilator. The assessment documented the resident was receiving intravenous therapy. A skin check sheet, dated 01/14/17, documented the resident had abrasion to his left posterior shoulder, a pressure ulcer to his sacrum, a pressure ulcer to his left buttock, and a moisture induced wound to his anterior neck below [MEDICAL CONDITION]. No measurements of the wounds were documented. The treatments documented were Xeroform to left shoulder daily. The sheet documented [MEDICATION NAME] to the anterior neck, [MEDICATION NAME] lined [MEDICATION NAME] every Monday, Wednesday, and Friday to be applied to the sacrum, and Xeroform daily to the left buttock. An ulcer/wound progress note, dated 01/14/17, documented, Stage IV- full thickness tissue loss with exposed bone, tendon, or muscle. The note documented the wound was red with a moderate quantity of serous drainage and a mild odor. The note documented the wound edges were flat and the periwound had a normal appearance. The progress note documented the treatment order was changed to pack the wound with [MEDICATION NAME] lined [MEDICATION NAME], cover with foam pad, and secure with [MEDICATION NAME] tape. A care plan, dated 01/17/17, documented the resident required total assistance with activities of daily living related to [MEDICAL CONDITION]. The care plan documented the resident had a [DIAGNOSES REDACTED]. The care plan documented the resident required [MEDICAL CONDITION] care and suctioning. The care plan documented the resident was verbally abusive at times. The care plan documented the resident had a [DIAGNOSES REDACTED]. The care plan documented the resident had a [MEDICAL CONDITION]. The care plan documented the resident had a potential for skin breakdown related to impaired mobility. The care plan did not document the resident had pressure ulcers. A skin check sheet, dated 01/28/17, documented the resident had an abrasion to his left posterior shoulder that measured 2.4 cm x 2.6 cm. The skin check sheet documented a wound to the sacrum that measured 6.8 cm x 7.2 cm x 3.2 cm. The skin check sheet documented an open wound to the left buttocks that measured 5.2 cm x 7.1 cm x undetermined. The skin check sheet documented a popped blister to the right lateral hip that measured 2 cm x 2.6 cm x <0.1 cm. The skin check sheet documented a popped blister to the right lateral knee that measured 2.3 cm x 2.6 cm x < 0.1 cm. The skin check sheet documented red areas to bilateral outer ankles. The skin check sheet documented the following skin treatments. Left shoulder (Xeroform) Sacrum ([MEDICATION NAME]) Left buttocks (Xeroform) Right lateral hip (Xeroform) Bilateral ankles ([MEDICATION NAME]) Anterior neck ([MEDICATION NAME]). The care plan, updated 02/01/17, documented the resident had multiple pressure ulcers placing him at risk for infection. The care plan did not document the number of pressure ulcers, the stage of the pressure ulcers, or the treatment to the pressure ulcers. A ulcer/wound progress sheet, dated 02/02/17, documented a stage IV full thickness pressure ulcer that measured 6.5 cm x 6.2 cm x 2.0 cm. The ulcer/wound progress sheet documented the wound had a moderate amount of serosanguinous drainage. The ulcer/wound progress sheet documented the wound had a mild odor. The ulcer/wound progress sheet documented the edges of the wound were flat and the periwound had a normal appearance. The ulcer/wound progress sheet documented a change in the treatment. The ulcer/wound progress sheet documented the wound was to be packed with [MEDICATION NAME] lined [MEDICATION NAME] with a dressing. The ulcer/wound progress sheet documented the resident was to have an air mattress on his bed as preventive equipment. A skin check sheet, dated 02/04/17, documented the resident had an abrasion to the left posterior shoulder. The skin check sheet documented the resident had a pressure ulcer to the sacrum, the left buttock, and to the anterior neck below [MEDICAL CONDITION]. No measurements were documented. The skin check documented the treatments as Xeroform daily to the left shoulder, [MEDICATION NAME] daily to sacrum, and [MEDICATION NAME] lined [MEDICATION NAME] every Monday, Wednesday, and Friday to the left ankle and apply Xeroform daily. A nurse note, dated 02/06/17, documented the resident complained of needing to be suctioned. The nurse note documented the resident's oxygen saturation was fluctuating between 79% and 84%. The nurse note documented the resident had a temperature of 99.9 axilliary. The nurse note documented emergency medical services was notified to transport the resident to the emergency room for evaluation. A nurse note, dated 02/07/17, documented the resident had been admitted to the hospital for the [DIAGNOSES REDACTED]. An operative report, dated 02/14/17, documented the resident had a sharp excisional debridement of the sacral and the left gluteal ulcers. The operative report documented the sacral decubitus total diameter as 10 cm x 7 cm x 3 cm measuring the tunnel as well. The operative report documented the left gluteal decubitus ulcer as 5.5 cm x 6.0 cm x 2.0 cm deep. The operative report documented the sacral decubitus was a stage IV and the gluteal decubitus as stage III. A narrative note, dated 02/23/17, documented the resident was readmitted to the facility with the [DIAGNOSES REDACTED]. The narrative note documented the resident had 2 small wounds to his right outer knee. One measured 3 cm x 4 cm and the other 2 cm x 2 cm . The narrative note documented the resident had a wound to his left ankle that measured 3 cm x 4 cm. The narrative note documented the resident had a wound to his left heel that measured 3 cm x 5 cm. The narrative note documented the resident had a wound to his left hip that measured 10 cm x 7 cm and 4 cm deep. A skin check sheet, dated 02/25/17, documented the resident had an abrasion to his back left shoulder that measured 2.1 cm x 2.2 cm. The skin check sheet documented the resident had an open area on the sacrum that measured 3.4 cm x 9.8 cm x 2.2 cm. The skin check sheet documented the resident had a wound to his left heel that measured 7.2 cm x 7.8 cm x 3.4 cm. The skin check sheet documented the resident had an open area to his left buttock that measured 2.8 cm x 3.6 cm. The skin check sheet documented the resident had an open area to his right lateral hip that measured 2.0 cm x 2.2 cm. The skin check sheet documented the resident had an open area to his right lateral knee that measured 3.2 cm x 3.8 cm. The skin check sheet documented the resident had an open area to his left outer ankle that measured 3.1 cm x 4.6 cm. The skin check sheet documented the resident had an area on the left heel and redness to left outer ankle. The skin check sheet documented to apply Xeroform to the right lateral hip, right lateral knee, left outer ankle and left heel every day. The skin check sheet documented to apply [MEDICATION NAME] to the redness of right outer ankle twice daily. The skin check sheet documented to apply [MEDICATION NAME] gauze packing everyday to the wounds on sacrum and left buttocks. The skin check sheet documented to apply [MEDICATION NAME] to the resident's anterior neck. A ulcer/ wound progress note, dated 03/01/17, documented the resident had an unhealed stage III pressure ulcer. The ulcer/wound progress note documented the wound described the wound as full thickness tissue loss. The ulcer/wound progress note documented the measurements as 6.0 cm in length, 6.0 cm in width, and 1.0 cm in depth. The ulcer/wound note documented the wound was located on the right buttocks. The wound was described as red with a severe amount of serosanguineous drainage. The ulcer/wound progress note documented the wound had a mild odor and the infection level was contained. The ulcer/wound progress note documented the resident had a stage IV wound that was full thickness tissue loss. The ulcer/wound progress note documented the measurements as 8.0 cm in length, 8.0 cm in width, and 1.2 cm in depth. The ulcer/wound progress note described the wound as red with a severe amount of serosanguineous drainage. A skin check sheet, dated 03/01/17, documented the resident had abrasions to his right scapula and right iliac crest. The skin check sheet documented the resident had a pressure ulcer to his coccyx and his right tuberosity. The skin check sheet documented the wounds were stage IV. The skin check sheet documented a wound as other right neck, right outside knee, right posterior knee, and left exterior knee all stage II. The wound sheet documented no measurements for these wounds. The skin check sheet documented the depth of the wound was half an inch. The skin check sheet documented the periwound was macerated and had [DIAGNOSES REDACTED]. The skin check sheet documented the treatment for [REDACTED]. A nurse note, dated 03/03/17 at 9:19 p.m., documented the resident was diaphoretic, yet freezing. The nurse note documented the resident had a temperature of 100.4 axilliary. The nurse note documented the resident was given 30 milliliters of ibuprophen via peg tube. The nurse note documented the resident was re-assessed at 20:30 p.m. and the resident had a temperature of 101.7 axilliary. The nurse note documented at 20:48 p.m., 911 was called to transport the resident to the emergency room for evaluation. A nurse note, dated 03/14/17, documented per orders re-admit to the facility from the hospital. A nurse note, dated 03/15/17, documented the resident's wound appeared the same as the previous day. A weight record, dated 03/17/17, documented the resident's weight as 117.4 pounds. On 03/20/17 at 10:55 a.m., the resident was observed during wound care. The resident was observed on a ventilator and was receiving nutrition via a peg tube. The resident appeared to be aware of his surroundings. Licensed practical nurse (LPN) #1 reported the resident was in contact isolation due to the [DIAGNOSES REDACTED]. Barrels with red biohazard bags and personal protective equipment were observed in the resident's room. The resident was observed to have a [MEDICAL CONDITION]. The [MEDICAL CONDITION] bag had become unattached and the resident and his bedding were soiled with fecal material. The LPN along with certified nurse aides #1 and #2 were observed to provide personal care for the resident. The LPN and CNAs #1 and #2 were observed to change their gloves when they became soiled with the fecal material. The LPN and CNAs #1 and #2 did not wash their hands with soap and water after changing gloves and before donning clean gloves. The LPN was observed to leave the room multiple times to obtain clean supplies and wound supplies for the resident. The LPN was not observed to wash her hands with soap and water before leaving the room to obtain the clean supplies. The LPN was not observed to wash her hands with soap and water before donning clean gloves or before beginning wound care on the resident. The LPN was asked to measure the resident's wounds before providing the wound care. The following wounds were measured: a) The right ankle measured 2 cm x 3 cm. The wound bed was covered with yellow slough and black eschar. The LPN was observed to use her gloved hand to apply [MEDICATION NAME] ointment to the wound. The resident was observed with streaking to the right lower leg. The LPN reported she had contacted the resident's physician the previous day and the physician stated the resident was currently on two antibiotics and did not wish to change orders at that time. b) The left ankle measured 2.2 cm x 1.5 cm. The wound bed was observed red with black eschar. The LPN was observed to use her gloved hand to apply [MEDICATION NAME] ointment to the wound. c) The left heel had brown discoloration that measured 4.5 cm x 2.6 cm. The left heel had black eschar that measured 3.5 cm x 3.8 cm. The LPN reported no treatment was being provided due to the area was dry and had no odor or drainage. d) The right heel had an area of brown/purple discoloration that measured 1.5 cm x 1.0 cm. e) The right outer leg/knee area was observed with two wounds. The first wound measured 0.5 cm x 1.0 cm. The wound bed was black. The second wound measured 1.0 cm x .05 cm. The wound bed was black. The LPN applied [MEDICATION NAME] and a bandage. f) The resident was observed with two areas of breakdown at [MEDICAL CONDITION]. The area was red and one area was open, pink in color, and measured 0.5 cm x 0.3 cm. The LPN placed a foam protection under the trach. The LPN applied [MEDICATION NAME] to the open area at [MEDICAL CONDITION]. The resident was repositioned to his left side. g) The sacrum wound was observed to be a stage IV. The wound bed was red, no odor, and no drainage. The wound measured 9.7 cm width x 8.3 cm length x 1.3 cm depth. The wound was observed to have tunneling at 5 p.m. with 1.0 cm. The wound had tunneling at 8 p.m. that measured 1.0 cm. The LPN was observed to apply [MEDICATION NAME] and a covering to the wound and apply a foam cover. h) The right buttocks measured 6.4 cm width x 4.0 cm length x 1.0 cm depth. The wound bed was observed red, no drainage, and no odor. The LPN was observed to apply [MEDICATION NAME] and a covering to the wound. j) The left buttocks measured 3.0 cm width x 2.5 cm length. The wound bed was black eschar. On 03/20/17 at 12:10 p.m., the director of nursing (DON) was asked to see the resident's skin assessments. The DON was asked if she was aware the resident had approximately 10 wounds. The DON reported she was not aware he had that many. The DON reported the resident was admitted to the facility with the sacral wound. On 03/20/17 at 1:45 p.m., the DON presented the skin assessments to the surveyor. The skin assessments were not observed to be consistent and the assessments did not contain all wound and/or measurements and staging. The DON reported she had given me all the resident's skin assessments she could find. On 03/20/17 at 2:41 p.m., the DON was asked if the resident's wounds had been assessed on his 03/14/17 hospital re-admission. The DON reported, No. The DON reported she was unable to find where a skin assessment had been completed on his 03/14/17 hospital re-admission. The DON was asked if the resident should have been assessed on his re-admission. The DON reported the resident's skin should have been assessed when he was readmitted from the hospital. The DON was asked what the facility's policy was on tracking wounds. The DON reported the residents were supposed to have their skin assessed every week. The DON reported the LPN charge nurses were responsible to measure any wounds the residents had on a weekly basis. The DON was asked if she had assessed the resident's wounds since his re-admission. The DON stated she had not seen his wounds. On 03/20/17 at 3:06 p.m., the dietary manager (DM) was interviewed regarding the nutritional status of the resident. The DM reported the resident was admitted with a feeding tube and was taking food and fluids by mouth. The DM reported the resident was receiving nutrition via a tube feeding only since his last hospital re-admission on 03/14/17. On 03/21/17 at 2:45 p.m., licensed practical nurse #1 was interviewed regarding the facility's policy and procedure regarding weekly skin assessments. The LPN reported she normally did not conduct the skin assessments. The LPN reported another nurse conducted them on Thursdays. The LPN was asked what was the procedure when a resident was readmitted from the hospital. The LPN reported the charge nurse should conduct a head to toe assessment with a skin assessment when readmitted from the hospital. The LPN reported the resident's primary care physician should also be contacted. The LPN was interviewed regarding the resident's pressure ulcers and treatments. The LPN reported the resident had treatments daily. The LPN reported the pressure ulcer on the resident's sacrum was deeper since he was readmitted from the hospital. The LPN reported the resident had a wound vac while in the hospital. The LPN reported this day was the first time she had measured the resident's wounds. The LPN reported the facility measured the resident's wounds on Thursdays and Saturdays. The LPN reported the resident's physician should be notified for any skin problems. The LPN reported the resident had to be repositioned frequently. The LPN reported the resident refused to be repositioned at times. On 03/22/17 at 9:15 a.m., the DON was asked if the resident's pressure ulcers had been assessed and measured. The DON reported the resident's pressure ulcers had not been assessed at that time. The DON reported she and the charge nurse would measure the wounds later that morning. On 03/22/17 at 10:00 a.m., the DON presented the surveyor with the resident's skin assessment. The DON reported the facility numbered each wound on the skin assessment sheet so the facility could better track the wounds. The DON was asked how many wounds were found on the resident. The DON reported the resident had 15 wounds. The resident's skin assessment, dated 03/22/15, documented the resident had 15 wounds. 03/22/17 at 11:15 a.m., the DON was interviewed regarding the facility's system for skin assessments. The DON reported the skin was to be checked every seven days on Saturdays. The DON was told by the surveyor she was unable to find consistent charting of skin measurements for the resident. The DON reported she would look to see what she could find. On 03/22/17 at 11:36 a.m., the DON was asked to review the nurse notes and skin assessments. The DON was asked for any further documentation to show the resident was admitted with the pressure ulcers. The DON was asked if the facility had a policy regarding weekly skin assessments and pressure ulcers. The DON reported the facility had a policy and would get it to the surveyor. The DON reported the facility no longer had a designated nurse to conduct the weekly skin assessments. On 03/22/17 at 5:44 p.m., the DON was interviewed. The DON was asked how she monitored and tracked the condition of the pressure ulcers in the facility. The DON was asked about the treatment orders not being changed on treatment administration record (TAR) since the resident's had been admitted to the facility. The DON was asked if she had any documentation regarding physician notification on the condition of the wounds or changes in treatment orders. The DON reported the facility would notify the resident's physician via phone when the resident had a new pressure ulcer or a change in an existing one, but did not have documentation for any new treatment orders. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A narrative note, dated 10/25/16, documented the resident was admitted to the facility with [DIAGNOSES REDACTED]. The narrative note documented the resident had contractures on all extremities. The narrative note documented the resident had a suprapubic catheter in place. The narrative note documented the resident had a feeding tube with Glucerna infusing at 45 cubic centimeters an hour. The narrative note documented the resident had brown scabbed areas on his toes bilaterally. The narrative note documented the resident had a small abrasion to the outer right lower extremity that measured 1.0 cm x 1.0 cm. The note described the depth as superficial. The narrative note documented the resident had open area on his left buttocks that measured 3.0 cm x 3.0 cm. The note described the depth as superficial. The narrative note documented the resident had an open area on his right buttocks that measured 4.0 cm x 4.0 cm. The note described the depth as superficial. An admission assessment, dated 10/31/16, documented the resident was rarely or never understood. The assessment documented the resident required extensive to total assistance with bed mobility, transfers, and all activities of daily living. The assessment documented the resident had impairment to both the upper and lower extremities. The assessment documented the resident had a catheter and was frequently incontinent with bowel. The assessment documented the resident had a feeding tube. The assessment documented the resident had a weight of 208 pounds. The assessment documented the resident had a risk of developing pressure ulcers. The assessment documented the resident was admitted with two stage II pressure ulcers. The assessment did not document the measurements of the pressure ulcers. The assessment documented the resident required oxygen therapy, suctioning, [MEDICAL CONDITION] care, and required a ventilator. On 11/01/16, the resident's clinical record documented the resident was admitted to the hospital. A nurse note, dated 11/17/16, documented the resident was readmitted to the facility with the [DIAGNOSES REDACTED]. The nurse note documented the resident had a stage II pressure ulcer to the outer aspect of his foot that measured 2.0 cm x 2.0 cm x 0.1 cm deep. The nurse note documented the resident had a stage II pressure ulcer to his right buttock that measured 3.0 cm x 3.0 cm x 1.0 cm deep. The nurse note documented the resident had red area to his left buttock that measures 4.0 cm x 5.0 cm. The nurse note documented new treatment orders. The nurse note was not specific to the treatment order. A treatment order, dated 11/18/17, documented the resident was to wear bunny boots at all times. A skin assessment weekly sheet, dated 11/19/16, documented the resident had an open area resolved to left buttocks. The skin assessment sheet documented the resident had an open area to the right buttocks that measured 1.8 cm x 3.0 cm. The assessment sheet documented the resident had scabbed areas on the lateral right foot and toes. An admission assessment, dated 11/24/16, documented the resident was rarely or never understood. The assessment documented the resident required total assistance with bed mobility, transfers, and all aspects of daily living. The assessment documented the resident had impairment to the upper and lower extremities. The assessment documented the resident had a catheter and was frequently incontinent of bowel. The assessment documented the resident had weight of 208 pounds. The assessment documented the resident was on a feeding tube. The assessment did not document the resident had skin problems. The assessment documented the resident required oxygen therapy, suctioning, [MEDICAL CONDITION] care, and a ventilator. A skin assessment weekly sheet, dated 11/26/16, documented the resident had an open area to the right buttocks and scabbed areas on the outer feet and toes. A skin assessment weekly sheet, dated 12/03/16, documented to apply [MEDICATION NAME] to redness to the buttocks and scabbed areas on the feet bilaterally. A significant change assessment, dated 12/07/16, documented the resident was rarely or never understood. The assessment documented the resident required total assistance with bed mobility, transfers, and all activities of daily living. The assessment documented the resident had impairment to both the upper and lower extremities. The assessment documented the resident had a catheter and was always incontinent of bowel. The assessment did not document a weight. The assessment documented the resident was on a feeding tube. The assessment documented the resident had a stage I area. The assessment documented the resident was at risk of developing a pressure ulcer. The assessment did not document any pressure ulcers or measurements of pressure ulcers. The assessment did not document any special treatment, procedures, or programs for the resident. A skin assessment weekly sheet, dated 12/10/16, documented the resident had scabbed areas on his toes and outer foot. The skin assessment sheet documented the resident had an area on the buttocks that measured 3.2 cm x 2.4 cm A narrative note, dated 01/02/17, documented the resident was readmitted to the facility from the hospital. The narrative note documented the resident was on a ventilator. The narrative note documented the resident had an [MEDICAL CONDITION] with an eviscerated wound. The narrative note documented a culture of the abdominal wound was ordered due to being positive for VRE. The na

On 03/22/17 at 5:45 p.m., the Oklahoma State Department of Health was notified an immediate jeopardy situation was determined to exist related to the facility's failure to provide proper hand hygiene after providing personal care for a resident with a [DIAGNOSES REDACTED]. On 03/22/17 at 6:01 p.m., the administrator and DON were notified of an immediate jeopardy situation regarding the facility's failure to provide proper hand hygiene after providing personal care for a resident with a [DIAGNOSES REDACTED]. The staff members did not wash their hands with soap and water before touching the resident, the resident's clean linens, leaving the room to obtain more supplies, and/or providing wound care. The administrator and DON were informed the IJ was related to the facility's failure to follow their infection control policy on preventing the spread of infection on a resident diagnosed with [REDACTED]. On 03/22/17 at 8:15 p.m. the administrator provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: Infection control 03/22/17 We will revise and review our policy and procedure for infection control. We will in-service all staff immediately on hand washing and infection control. We will in-service will be completed by midnight In-service will be conducted by Administrator, DON, ADON<br(NAME)Rogers Staff will be in-serviced at facility by phone to include any employee not present. DON or designee shall oversee implementation survelance 2 x week per 12 hour shift for 2 weeks. 1 x per 12 hour shift for 2 weeks. All new employees will trained upon hire. Discussed at QA. No alcohol gel for[DIAGNOSES REDACTED] attached policy to signature page. On 03/23/17 at 4:04 p.m., an addendum to plan of removal documented: All licensed staff will be re-inserviced on infection control policy and procedures, hand washing/hygiene policy and procedures and wound care policy and procedures. In-services will be completed by 6:00 pm 3/23/17. On 03/27/17 at 10:40 a.m., facility staff members interviewed and verbalized understanding of the facility's policy and procedures regarding infection control and the prevention of cross contamination during wound care. The nursing staff verbalized understanding. The administrator was informed the immediacy had been lifted effective 03/23/17 at 7:15 p.m. The administrator was informed the deficiency remained at a harm level at a pattern and the facility remained in substandard quality of care. Based on observation, interview, and record review, it was determined the facility failed to ensure resident care was provided in manner that prevented cross contamination for one (#2) of six residents sampled for wound care. The facility failed to practice proper hand hygiene after providing personal care for a resident diagnosed with [REDACTED]. to obtain more supplies, and/or provide wound care without providing proper hand hygiene. The facility identified one resident with the [DIAGNOSES REDACTED]. Findings: The facility's policy on hand hygiene documented all personnel would follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy documented hands would be washed with soap and water when they became visible soiled and after contact with infections caused by [DIAGNOSES REDACTED]icile 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 01/09/17, documented the resident was rarely or never understood. The assessment documented the resident exhibited verbal behaviors towards others 4-6 days a week. The assessment documented the resident required total assistance with bed mobility, transfers, and activities of daily living. The assessment documented the resident had an ostomy and a catheter. The assessment documented the resident had a tube feeding. The assessment documented the resident was at risk of developing a pressure ulcer. The assessment documented no skin problems or pressure ulcers. The assessment documented the resident required oxygen therapy, suctioning, tracheostomy care, and a ventilator. The assessment documented the resident was receiving intravenous therapy. A care plan, dated 01/17/17, documented the resident required total assistance with activities of daily living related to quadriplegia. The care plan documented the resident had a [DIAGNOSES REDACTED]. The care plan documented the resident required tracheostomy care and suctioning. The care plan documented the resident was verbally abusive at times. The care plan documented the resident had a [DIAGNOSES REDACTED]. The care plan documented the resident had a colostomy. The care plan documented the resident had a potential for skin breakdown related to impaired mobility. The care plan did not document the resident had pressure ulcers. A nurse note, dated 03/01/17, documented due to positive[DIAGNOSES REDACTED] result per new order, [MEDICATION NAME] 125 mg by mouth four times a day x 15 days. On 03/20/17 at 10:55 a.m., the resident was observed during wound care. The resident was observed on a ventilator and was receiving nutrition via a peg tube. The resident appeared to be aware of his surroundings. Licensed practical nurse #1 (LPN) reported the resident was in contact isolation due to the [DIAGNOSES REDACTED]. Barrels with red biohazard bags and personal protective equipment were observed in the resident's room. The resident was observed to have a colostomy. The colostomy bag had become unattached and the resident and his bedding were soiled with fecal material. The LPN along with certified nurse aides #1 and #2 were observed to provide personal care on the resident. The LPN and CNAs #1 and #2 were observed to change their gloves when the gloves became soiled with the fecal material. The LPN and CNAs #1 and #2 did not wash their hands with soap and water after changing gloves and before donning clean gloves. The LPN was observed to leave the room multiple times to obtain clean supplies and wound supplies for the resident. The LPN was not observed to wash her hands with soap and water before leaving the room to obtain the clean supplies. The LPN and the CNAs were not observed to wash to wash their hands with soap and water after changing soiled gloves and before touching the resident and the resident's clean linen. The LPN and the CNAs removed their soiled gloves and placed them in the isolation barrel. The LPN and the CNAs were not observed to wash their hands before leaving the room. On 03/22/17 at 5:40 p.m., the DON was interviewed regarding the facility's infection control policy regarding isolation. The DON reported an isolation sign should be on the door. The DON reported there should be barrels lined with biohazard bags in the resident's room. The DON reported gloves should be put on after entry to the resident's room. The DON reported soiled gloves should never be worn out of the room. The DON reported the staff should always wash their hands prior to leaving the room especially if a resident was in isolation. The DON reported alcohol gel should never be used with[DIAGNOSES REDACTED]. The DON reported the facility had presented an in-service over infection control several times. The DON reported there were no other residents with the [DIAGNOSES REDACTED]. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 12/07/16, documented the resident was rarely or never understood. The assessment documented the resident required total assistance with bed mobility, transfers, and all activities of daily living. The assessment documented the resident had impairment to both the upper and lower extremities. The assessment documented the resident had a catheter and was always incontinent of bowel. The assessment did not document a weight. The assessment documented the resident was on a feeding tube. The assessment documented the resident had a stage I area. The assessment documented the resident was at risk of developing a pressure ulcer. The assessment documented did not document any pressure ulcers or measurements of pressure ulcers. The assessment did not document any special treatment. procedures, or programs for the resident. A care plan, dated 01/17/17, documented the resident had skin breakdown. The care plan documented the resident had impaired mobility related to functional [DIAGNOSES REDACTED]. The care plan documented the resident had a potential for altered nutrition related to a gastrostomy tube. The care plan documented the resident had a potential for altered body image related to a colostomy. The care plan documented the resident required total care with activities of daily living. The care plan documented the resident was dependent on a ventilator. The care plan documented the resident had cognitive loss and dementia. The care plan documented the resident had an indwelling suprapubic catheter. The care plan documented the resident had a tracheostomy and required tracheal suctioning. On 03/23/17 at 10:06 a.m., the resident was observed during wound care. Licensed practical nurse (LPN) #2 entered the room with a red bag. The LPN was not observed to provide hand hygiene before donning clean gloves. The LPN was observed to remove the dressing from the coccyx. The LPN then removed the soiled gloves and donned clean gloves. The LPN was observed to change her soiled gloved when removing soiled dressings and before applying a clean dressing. The LPN was not observed to provide hand hygiene at anytime during the dressing change. During the dressing changed the LPN dropped a dressing on the bed. The LPN picked up the dressing and applied it to the resident's foot. On 03/23/17 at 10:54 a.m., LPN #2 was interviewed regarding maintaining infection during wound care. The LPN reported hands should be wash with soap and water before and after care. The LPN reported gloves should be changed between dirty and clean dressings. On 03/23/17 at 1:45 p.m., The DON was asked about the facility's policy and procedure regarding infection control during dressing change. The DON reported the nurse should have all supplies ready and have a clean trash bag for dirty dressings. The DON reported the nurse should wash her hands after they enter the resident's room and between gloves changes. The DON was asked what her expectation was for a nurse who is changing dressings on a resident with multiple wounds. The DON reported the nurse should wash her hands between glove changes. The DON reported she was aware the staff was not providing hand hygiene between glove changes. The resident's wound care was discussed with the DON. The DON was asked what she would have expected to see. The DON reported the LPN had cross contaminated by not washing her hands between the clean and dirty dressings changes on the resident.

On 10/21/14 at 6:45 p.m., the Oklahoma State Department of Health (OSDH) was notified of a immediate jeopardy (IJ) situation related to the facility's failure to protect a resident from mistreatment. A staff member held a resident against the wall and was cussing during his contact with the resident. On 10/21/14 the OSDH verified an immediate jeopardy situation existed related to the facility's failure to protect a resident from mistreatment. On 10/21/14 at 7:10 p.m., the administrator, assistant director of nursing, and general manager were informed of the IJ situation related to the facility's failure to protect a resident from mistreatment. The administrator, director of nursing, and general manager were informed the immediate jeopardy situation constituted substandard quality of care. The administrator, director of nursing, and general manager verbalized understanding. On 10/21/14 at 9:50 p.m., the director of nursing, assistant director of nursing, and general manager, provided the survey team with an acceptable plan of removal. The plan of removal presented by the facility documented the following: "Plan of removal This facility will suspend Administrator immediately until further notice. This facility will notify, the Board of Examiners for Administration and the owners of Medi Home of Arkoma within 24 hours. The Administrator will be In-serviced by (name deleted), on the abuse policy and also, the use of foul language around residents & to be mindful of a residents personal space. Administrator will be inserviced via phone by 4:00 p.m. on [DATE]. The Admin will be inserviced by (name deleted) on residents rights. This facility will In-service all staff on duty, immediately, regarding the 7 components of Abuse, and the Abuse Policy and Procedure. This facility will In-service on Abuse, Verbal Abuse, Sexual Abuse, Physical Abuse, Mental Abuse and involuntary seclusion. This facility will In-service all staff on, Screening, Training, Prevention, Identification, Investigation, and Protection, Reporting and Response, Quality Assurance. GM, DON, ADON will in-service all remaining Employees, part time employees and PRN staff before returning to work. This In-service will include the following: 7 components of Abuse, and the Abuse Policy and Procedure. This facility will In-service on Abuse, Verbal Abuse, Sexual Abuse, Physical Abuse, Mental Abuse and Involuntary Seclusion, Screening, Training, Prevention, Identification, Investigation and Protection, Reporting and Response, Quality Assurance. This inservice will be mandatory at 11 am on 10/22/14. This facility will also in-service on Care Plan updating notifying family, notifying Physician, Residents Rights and Dignity and monitoring Resident for signs of reactions related to abuse. This facility will provide an ongoing In-service training for all Employee's as to appropriate interventions that deal with aggressive and/or catastrophic reactions of Residents to abuse. This Facility will provide training on how staff should report their knowledge related to allegations without fear or reprisal, how to recognize signs of burnout, frustration, and stress that may lead to abuse, what constitutes abuse, neglect, and misappropriation of residents property. This facility will investigate all alleged violations, and will protect the resident from further potential abuse while the investigation is in progress. All residents, staff and family will be included in the investigation and allegations will be reported to regulating authorities within 24 hour time frame and the employee will be immediately suspended pending the outcome of that investigation to protect the resident. Policy and Procedures will be followed on all allegations of abuse. If the allegation is against the Administrator or DON then the General Manager or ADON will be notified. This facility will In-Service and continue to train Employee's, Family Members and Residents on how to recognize signs of abuse. This facility will screen all Employee's for a history of abuse, neglect, or mistreatment of residents by obtaining all proper paper work. Administrator In-serviced via telephone on [DATE], 3:30 P.M by (name deleted) Administrator in-serviced on the Abuse Policy of Medi-Home of Arkoma, Admin, was Also in-serviced on using foul language in front of residents, being mindful of residents personal space, and In-serviced on Residents Rights, and dignity issues. Admin, was also in-serviced on his job duties. Administrator was also in-serviced on making sure all incidents involving Residents be documented correctly and in a timely manner." Surveyors interviewed staff on all shifts to verify their knowledge of the facility's abuse policy and procedure related to the seven components. The staff verbalized an understanding of the facility's abuse policy related to the seven components. On 10/22/14 at 3:30 p.m., the facility was informed the immediate jeopardy was removed effective 10/22/14 at 3:30 p.m., when the last staff member had been in-serviced and staff verbalized an understanding of the facility abuse policy related to the seven components. The deficiency remained at a level of no actual harm with potential for more than minimal harm at a pattern level. Based on observation, interview, and record review, it was determined the facility failed to protect a resident from mistreatment for one (#1) of six residents who were sampled for abuse and/or mistreatment. Resident #1 was held against the wall by a staff member and the staff member was cussing during his contact with the resident. The facility failed to: a. Implement their policy for an allegation of verbal abuse and mistreatment for resident #1. b. Protect resident #1 from further potential verbal abuse and mistreatment. c. Thoroughly investigate an allegation of verbal abuse for resident #1. d. Report an allegation of verbal abuse for resident #1. The facility identified four allegations of abuse within the last six months. Findings: The facility's abuse prohibition policy documented residents had a right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy documented verbal abuse was defined as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, or ability to comprehend. The policy documented in the event of any evidence or cause to believe that a resident has suffered any of the above abuses the employee, visitor or family members are requested to report all allegations, suspensions or incidents to the administrator of the facility. The policy documented upon a report of any allegations or violations the administrator of their designated representative would thoroughly investigate the situation in accordance with Oklahoma law. The policy documented any employee suspected of abuse or neglect would be suspended from employment with or without pay. The policy documented the investigation would include the names of all individuals involved, witnesses that actually viewed the incident, the resident's statement concerning the incident, when and where the incident occurred, and any evidence of injury or abuse present on the residents body or in the residents action. The policy documented the results of all investigations are reported to the administrator and/or their representative. The policy documented the facility would notify the licensing agency and/or local authorities immediately per telephone and within five working days, and would pursue the following steps of notification of the responsible party, employee discipline, and notification of other interested parties or agencies. The policy documented the nursing home would investigate all alleged violations and would protect the resident form further potential abuse while the investigation was in progress. The policy documented the nursing home would report to the state registry and state licensing authorities any knowledge it had of actions by a court of law against an employee that would indicate unfitness for service. The policy documented the abuse be reported to the administrator within eight hours. The policy documented the administrator or their designee would fax the state health care authority and the department of human services within 24 hours following the discovery by the facility. The policy documented the facility would then fax the five day follow up report. The policy documented if the allegation was verified, appropriate corrective action would be taken. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 12/11/13, documented the resident had modified independence with cognitive skills. The assessment documented the resident had short and long term memory problems. The assessment documented the resident had physical behaviors toward others 1-3 days in the last seven days. The assessment documented the resident had verbal and other behaviors toward others 4-6 days in the last seven days. The assessment documented the resident was independent with transfers and ambulation. A social services/activity note, dated 08/07/14, documented the resident's behavior was "up" that morning. The note documented the resident would not sit down. The note documented the resident was pacing and wanting to go to the store with his brother. The note documented while attempting to redirect the resident's behavior, the resident became combative and put the activity director (AD) in a "headlock." The AD documented she told the resident she was trying to help him. The note documented the resident let go of the AD. The note documented the resident stated he was sorry. A quarterly assessment, dated 08/18/14, documented the resident had modified independence with cognitive skills. The assessment documented the resident had hallucinations and delusions. The assessment documented the resident had physical behavioral symptoms directed toward others 1-3 days in the last seven days. The assessment documented the resident had verbal and other behavioral symptoms 4-6 days in the last seven days. The assessment documented the resident was independent with transfers and ambulation. The assessment documented the resident required minimal assistance with activity of daily living needs. A social services/activity note, dated 08/19/14, documented the resident's behavior was "up" that morning and the resident would not sit down. The note documented the resident was pacing the floor. The note documented while attempting to redirect the resident's behavior, the resident became verbally abusive and combative with staff. The note documented the director of nursing assisted and was successful with redirecting the resident's behavior. A care plan, updated 08/21/14, documented the resident had short and long term memory problems. The care plan documented the resident required assistance with activities of daily living needs. The care plan documented the resident was at risk for behaviors related to mental [MEDICAL CONDITIONS] disorder, and [MEDICAL CONDITION] disorder. The care plan documented the resident became easily annoyed and angered by others. The care plan documented the staff would give the resident space and allow him to calm down. The care plan documented the resident had hallucinations. The care plan documented the staff would monitor and document the resident's behavior. The care plan documented the resident would yell and curse when upset. The care plan documented the staff would redirect the resident. The care plan did not document specific interventions for the staff to redirect the resident's abusive behaviors. A social services/activity note, dated 09/04/14, documented the resident's behavior was "up" the last few days. The note documented the resident would not sit down and was always standing up or walking. The note documented the resident was easily agitated. The note documented the resident became verbally abusive and combative when attempting to redirect behavior. A behavior monitoring sheet, dated 10/06/14, documented the resident refused to be toileted on rounds at 2:00 a.m., 4:00 a.m., and 6:00 a.m. The sheet documented the resident threw a fit, cursed, hit, and kicked staff. The sheet documented the resident reported he would rather wet himself because he was too tired to use the bathroom. The sheet documented the resident punched the staff in the face. On 10/21/14 at 11:45 a.m., the resident was observed in the dayroom visiting with other residents. On 10/21/14 at 12:30 p.m., staff member #1 was interviewed on how the facility educated the staff on resident's rights and abuse. The staff member reported the facility conducted abuse in-services at least twice yearly. The staff member was asked what the staff members were trained to do when an allegation of abuse was reported. The staff member reported the staff should first make sure the resident was safe, remove the perpetrator, and investigate the allegation. The staff member reported an abuse survey would be conducted from the residents. The staff member was asked if any allegations had been reported to her. Staff member #1 reported she had been made aware of an allegation of abuse between the administrator and resident #1 by another staff member. Staff member #1 reported she had been told the administrator cursed at resident #1. During the interview on 10/21/14 at 12:30 p.m., staff member #1 reported staff member #2 told her the administrator called her into his office and asked her, "What's the deal?" Staff member #2 reported she knew he was the administrator but he shouldn't be allowed to get away with it. Staff member #2 reported to staff member #1 the administrator threatened to fire her. Staff member #1 was asked by the surveyor if she considered this an allegation of abuse. Staff member #1 stated, "Yes." Staff member #1 was asked if she had reported this allegation. Staff member #1 stated, "No. I was afraid I would be fired." Staff member #1 reported she had viewed the video from the security camera. Staff member #1 reported she had asked the beautician if she had heard anything in the hallway. The staff member reported the beautician reported she had not heard anything. Staff member #1 reported staff member #2 told her the administrator came around the corner and pushed resident #1 against the wall. Staff member #1 reported she viewed the video during the time of the alleged incident. Staff member #1 reported she did not witness this incident. Staff member #1 reported the incident had been reported to her direct supervisor. On 10/21/14 at 12:55 p.m., staff member #2 was interviewed regarding the facility's abuse policy. Staff member #2 reported the facility had regular in-services on abuse. Staff member #2 reported if any resident abuse was witnessed the director of nursing would be notified. Staff member #2 was asked if she had ever witnessed any abuse. Staff member #2 stated, "Yes." The staff member reported on October 14, 2014 she witnessed an incident between the administrator and resident #1 in the hall by the dining room. Staff member #2 reported she had tried to get resident #1 to sit down and wait his turn at the beauty shop. Staff member #2 reported resident #1 grabbed her and she asked an unidentified staff member to get help. Staff member #2 reported the administrator came to help. Staff member #2 reported by the time the administrator arrived at the scene, the incident was over. Staff member #2 reported the administrator pushed resident #1 against the wall with his body. Staff member #2 reported staff member #1 came and helped the resident to a seat. Staff member #2 reported she went to the administrator's office and told him he was wrong. Staff member #2 reported she told the administrator she did not want to cause trouble. Staff member #2 reported the administrator told her to do what she needed to do. Staff #2 reported the administrator called the resident vulgar names. Staff #2 stated, "I did not know what to do." On 10/21/14 at 1:45 p.m., staff member #3 was interviewed regarding the facility's policy on abuse. The staff member reported any allegation of abuse would be reported to the office and then reported to the state. Staff member #3 was asked if she was aware of any recent abuse allegations. Staff member #3 stated it was reported to her the administrator was rough with resident #1 in the hallway. The staff member reported she was not at work when the incident took place. Staff member #3 stated she was not sure if the incident was reported. On 10/21/14 at 5:27 p.m., the administrator was asked if he had been accused of an allegation of abuse. The administrator reported he had been accused by an employee. The administrator reported resident #1 would hit you. The administrator stated, "I got up in the face of resident #1 so he would not hit me." The administrator reported the resident had hit him a couple of times before. The administrator reported if you stood at an arms length the resident would hit you. The administrator reported he had stood close to the resident so he would not hit him. During the interview on 10/21/14 at 5:27 p.m., the administrator reported the resident was in the haircut line. The administrator reported the resident was trying to hit staff member #2. The administrator reported he had gotten close to the resident to keep him from hitting staff member #2. The administrator was asked if he had said anything to the resident. The administrator stated, "I told him I could not put up with his bull." The administrator was asked if he cursed. The administrator stated, "I probably did. I was upset." The administrator reported he did not remember what he said. The administrator was asked if he reported this allegation. The administrator reported he had not considered this an allegation. The administrator reported he had considered this an incident with resident #1. During the interview on 10/21/14 at 5:27 p.m., the administrator reported if the resident did not sleep at night, the facility would have behavior problems the next day. The administrator reported the resident was standing among five or so residents. The administrator reported he was trying to get him away from the other residents. The administrator was asked if he had to intervene on behalf of the resident's behavior. The administrator reported he had to intervene at least twice daily. The administrator reported the resident would get real loud at times. The administrator reported resident #1 upset the other residents. The administrator reported he sometimes had to raise his voice and get harsh with resident #1. The administrator reported if resident #1 became upset he would swing. The administrator reported he was trying to keep him from hitting other residents. During the interview on 10/21/14 at 5:27 p.m., the administrator reported the resident knew what he was doing. The administrator reported to his knowledge resident #1 had not hit any residents. The administrator reported if he had said a bad word, he was just using language. The administrator reported he was not cursing the resident. The administrator reported a staff member reported to him she thought he was being mean to the resident. The administrator reported he was trying to keep the resident from hitting her. The administrator was asked if the surveyors could view the video from the security camera. The administrator agreed to allow the surveyors to view video from the camera. On 10/21/14 at 5:22 p.m., the surveyors viewed the video during the time of the alleged abuse allegation. Staff member #2 was observed to attempt to get resident #1 to sit in a chair several times without success. Resident #1 was observed to grab and push staff member #2. Resident #1 was observed standing at the end of the hallway. Staff member #2 was observed standing close with her hand outreached toward the resident's chest. The administrator was observed to approach resident #1. The administrator was observed to stand close to the resident. The resident was observed to have his back against the wall. The administrator was observed to assist resident #1 to the dining room. No audio was available. On 10/21/14 and 10/22/14 social services/activity notes for the month of October 2014 were requested from the social services/activity director. Social service/activity notes were not provided by the facility for the month of October 2014 prior to the end of the survey exit.

On 04/24/13 at 5:30 p.m., an Immediate Jeopardy (IJ) situation was identified related to the facility's failure to: a. have an extra [MEDICAL CONDITION] cannula of the correct size accessible at the residents' bedsides in case of an emergency. b. have a supply of easily accessible suction catheters. c. have a manual resuscitator that was immediately available. d. provide training for staff for care of tracheostomies. Residents #2 and #12 had Shiley tracheostomies and did not have replacements in the facility. Physician orders [REDACTED]. The facility did not have a written policy and procedure for maintaining sufficient supplies and emergency equipment at the residents' bedsides. Nurses' notes documented the residents had multiple upper respiratory tract infections since admissions. An IJ was verified by the Oklahoma State Department of Health (OSDH). On 04/24/13 at 6:00 p.m., the administrator and director of nurses (DON) were notified of the IJ situation related to the failure to provide care and services for two residents with tracheostomies. On 04/24/13 at 6:35 p.m., an acceptable plan of removal of the immediacy was provided. The plan of removal documented: "(Facility name deleted) will send all [MEDICAL CONDITION] Residents to (name-deleted) hospital(s) for a [MEDICAL CONDITION] change as soon as possible. An additional [MEDICAL CONDITION] is located at each [MEDICAL CONDITION] resident's bedside and is easily accessible. Ambu Bags and Oxygen sources are located at bedside and are easily accessible. Suctioning is also located at beside and is easily accessible. Extensive Training regarding [MEDICAL CONDITION] Care will be done for all Nurses immediately and at the of hire (sic). Nurses will be educated by DON and ADON before starting to work. There will be an initial hands on In-service, according to [MEDICAL CONDITION] Policy and [MEDICAL CONDITION] Change Policy. No Nurse will be allowed to work on the floor until the [MEDICAL CONDITION] In-service is completed. All nurses were called in for an immediate [MEDICAL CONDITION] Care and [MEDICAL CONDITION] change Training In-Service. Nurses will check off [MEDICAL CONDITION] Care and Emergency [MEDICAL CONDITION] Change every Month x 3 then Every 3 Months x 4, then every 6 Months thereafter. The facility will follow Manufacturers guidelines regarding all [MEDICAL CONDITION] changes. All C.N.A's and C.M.A's will be In-serviced on what steps to take in an emergency and signs of distress regarding all [MEDICAL CONDITION] residents. This will be QA'd every weekly (sic) x 1 month then 1 month x 3 then reevaluated." The IJ was removed effective 04/24/13 at 7:50 p.m., after all components of the plan of removal had been completed. Staff interviews were conducted to determine knowledge of the measures to take in the event of an emergency removal of a [MEDICAL CONDITION] from a resident. The policy and procedure was reviewed for emergency removal of a [MEDICAL CONDITION]. Residents with tracheostomies were observed to have emergency [MEDICAL CONDITION], suction catheters, and Ambu bags at their bedsides. The deficient practice remained at actual harm at a pattern level. Based on observation, record review, and interview, it was determined the facility failed to provide treatment and care for tracheostomies for two (#2 and #12) of two sampled residents reviewed for tracheostomies. The facility failed to: a. have a policy and procedure for [MEDICAL CONDITION] care. b. provide training for staff for care of tracheostomies. c. have an extra [MEDICAL CONDITION] cannula of the correct size accessible at the residents' bedsides in case of an emergency. d. have a supply of easily accessible suction catheters. e. have a manual resuscitator that was immediately available. f. follow the manufacturer's recommendation on changing the [MEDICAL CONDITION]. Residents #2 and #12 had Shiley tracheostomies and did not have replacements in the facility. Physician orders [REDACTED]. The facility did not have a written policy and procedure for maintaining sufficient supplies and emergency equipment at the residents' bedsides. Nurses' notes documented the residents had multiple upper respiratory tract infections since admissions. Findings: The package insert for the Shiley [MEDICAL CONDITION] was classified as a disposable medical device. Frequent and routine changes of the [MEDICAL CONDITION] were recommended. The manufacturer recommendation for the Shiley [MEDICAL CONDITION] documented the [MEDICAL CONDITION] usage was not to exceed 29 days. On 04/24/13 at 1:30 p.m., the facility was asked for a policy for emergency [MEDICAL CONDITION] decannulation. The director of nurses (DON) stated the facility did not have one. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission nursing assessment, dated 10/26/12, documented the resident was admitted from the hospital with a [MEDICAL CONDITION]. The assessment documented the resident required suctioning and the [MEDICAL CONDITION] did not have an inner cannula. The assessment documented the resident would be sent back to the hospital to have a Shiley [MEDICAL CONDITION] placed. The comprehensive admission assessment, dated 11/06/12, documented the resident was severely impaired for daily decision making and required total assistance with activities of daily living (ADLs). The assessment document the resident required the use of a [MEDICAL CONDITION]. The admission narrative nurse's note, dated 10/26/12 at 4:50 p.m., documented the resident had a [MEDICAL CONDITION] and was on five liters of oxygen via [MEDICAL CONDITION] mask. A temporary care plan, dated 10/26/13 at 2:10 p.m., documented the resident was comatose, was dependent on staff for all needs, and was to be turned and repositioned every two hours. The care plan documented the resident was to be kept free from respiratory tract infections. A telephone order, dated 10/28/12 at 2:37 p.m., documented an order for [REDACTED]. A nurse's note, dated 10/29/12 at 3:09 p.m., documented signs and symptoms of respiratory distress, labored breathing, and blood in the sputum. The note documented a telephone order was received at that time to send the resident to the hospital for evaluation. A nurse's note, dated 10/29/12, documented the resident returned on 10/29/12 at 4:55 p.m. with new orders for an antibiotic for an upper respiratory infection. A physician's orders [REDACTED]. A telephone order, dated 11/03/12 at 3:55 p.m., documented an order to send the resident to the hospital related to respiratory distress. A narrative nurse's note, dated 11/08/12 at 4:02 p.m., documented the resident had returned from the hospital with a [DIAGNOSES REDACTED]. A comprehensive care plan, dated 11/19/12 at 5:08 p.m., documented the resident's [MEDICAL CONDITION] site was to be kept clean and free from infection. A nurse's note, dated 12/18/12 on the 2-10 shift, documented the resident had a temperature of 100.1 degrees Fahrenheit (F) and was medicated with Tylenol. A nurse's note, dated 12/19/12 at 8:14 a.m., documented the resident had received orders for an antibiotic to treat an upper respiratory tract infection. A quarterly assessment, dated 01/25/13, documented the resident's cognition was severely impaired for daily decision making. The assessment documented the resident was dependent on staff activities of daily living and required care for a [MEDICAL CONDITION]. A nurse's note, dated 01/30/13 at 6:23 a.m., documented the resident was placed on an antibiotic for an upper respiratory infection. A nurse's note, dated 02/20/13 at 5:55 a.m., documented the resident was placed on an antibiotic for an upper respiratory infection. A nurse's note, dated 03/10/13 at 6:07 a.m., documented the resident was placed on an antibiotic for an upper respiratory infection. A nurse's note, dated 04/12/13 at 9:55 a.m., documented the resident was placed on an antibiotic for an upper respiratory infection. On 04/24/13 at 4:30 p.m., the resident's room was observed. The resident had one suction catheter but did not have an Ambu bag, extra [MEDICAL CONDITION], or suction catheters at the bedside. On 04/24/13 at 4:40 p.m., licensed practical nurse (LPN) #1 was asked what measures had been put in place if decannulation was to happen to residents with a [MEDICAL CONDITION]. The LPN stated no measures were in place. The LPN stated there had not been any education for emergency decannulation procedures and did not feel comfortable taking care of residents with a [MEDICAL CONDITION]. On 04/24/13 at 4:55 p.m., the director of nurses (DON) was asked if any education for emergency decannulation of the residents with a [MEDICAL CONDITION] had been done. The DON stated there had not been any education regarding emergency [MEDICAL CONDITION] care. The DON was asked how often the [MEDICAL CONDITION] was changed. The DON stated she did not know how often they were to be changed. The DON was asked if the [MEDICAL CONDITION] had been changed for the residents. The DON stated the tracheostomies had not been changed since the resident's admissions. The DON was asked if an extra [MEDICAL CONDITION] was kept at the bedside for emergency decannulation. The DON stated she was unaware that it was required. The DON was asked if an Ambu bag was kept at bedside for emergency. The DON stated no there was not an Ambu bag available. The DON was asked if extra suction catheters were kept at the bedside. The DON stated no they kept one suction catheter at a time in the bedside cabinet. On 04/24/13 at 6:05 p.m., the medical director was interviewed regarding the development of a policy for [MEDICAL CONDITION] care. The medical director stated she was not involved in development of any policy regarding the [MEDICAL CONDITION] care. On 04/24/13 at 6:15 p.m., the resident's attending physician was asked how often the Shiley [MEDICAL CONDITION] was to be replaced. The physician stated she was unaware of the Shiley manufacturer's recommendations regarding the time frame of replacement of the [MEDICAL CONDITION]. 2. Resident #12 was admitted to the facility on 01/09/13 with [DIAGNOSES REDACTED]. The admission assessment, dated 01/15/13, documented the resident was severely impaired for daily decision making and required assistance with activities of daily living (ADLs). The assessment documented the resident required the use of a [MEDICAL CONDITION]. The care plan, dated 01/17/13, documented to provide [MEDICAL CONDITION] care as needed. On 04/24/13 at 3:30 p.m., the resident was observed sitting in her Geri-chair. The resident's [MEDICAL CONDITION] was observed intact. The resident's room did not have an Ambu-bag at bedside, extra suction, suction catheters, or an extra [MEDICAL CONDITION] at the bedside in case of emergency decannulation. On 04/24/13 at 6:04 p.m., LPN #2 was interviewed regarding emergency care for residents with tracheostomies. The LPN was asked if she was trained in emergency care for residents with tracheostomies. The LPN stated, "No." The LPN stated she did not feel comfortable taking care of residents with tracheostomies. On 04/24/13 at 6:15 p.m., LPN #3 was interviewed regarding emergency care for residents with tracheostomies. The LPN stated she had not been educated on what to do in the event of an emergency with the residents with tracheostomies.